Basic Information
| Provider Information | |||||||||
| NPI: | 1942772942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GLOVER | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | |||||||||
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| Credential: | BCABA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 INTERNATIONAL PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327465028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666100580 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1237 AUGUSTA WEST PKWY | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309091807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7626854340 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2019 | ||||||||
| LastUpdateDate: | 02/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | 0-18-9404 | SC | N | 103K00000X | SC | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.