Basic Information
| Provider Information | |||||||||
| NPI: | 1659967859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KLUGE | ||||||||
| FirstName: | NICOLE | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6060 N COLLEGE AVE | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462201907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3178155501 | ||||||||
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| Practice Location | |||||||||
| Address1: | 91 MAIN ST UNIT 115 | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | RI | ||||||||
| PostalCode: | 028854437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783156260 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2020 | ||||||||
| LastUpdateDate: | 12/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | MA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.