Provider Demographics
NPI:1760819890
Name:MAMMINA, NICOLE (BCBA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MAMMINA
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 NEW HAMPSHIRE ST
Mailing Address - Street 2:APT 25
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-1301
Mailing Address - Country:US
Mailing Address - Phone:516-509-8068
Mailing Address - Fax:
Practice Address - Street 1:15 NEW HAMPSHIRE ST
Practice Address - Street 2:APT 25
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-1301
Practice Address - Country:US
Practice Address - Phone:516-509-8068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1-13-13666103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst