Basic Information
| Provider Information | |||||||||
| NPI: | 1952800229 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HEATH | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | |||||||||
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| Credential: | MA, BCBA, LBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 814 TYVOLA RD STE 126 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282173539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9807851113 | ||||||||
| FaxNumber: | 9807851114 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 OLD WINSTON RD | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272847124 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9807851113 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2018 | ||||||||
| LastUpdateDate: | 08/18/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 11471260-2506 | UT | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1-19-37759 | UT | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 106E00000X | 11230040-2507 | UT | N | 106S00000X | N | 103K00000X | 1-19-37759 | NC | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.