Provider Demographics
NPI:1437697083
Name:LIPOWSKI, NICOLE GRIFFIN (BCBA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:GRIFFIN
Last Name:LIPOWSKI
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:MISS
Other - First Name:MORGAN
Other - Middle Name:NICOLE
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BCBA
Mailing Address - Street 1:8223 W 141ST ST
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2323
Mailing Address - Country:US
Mailing Address - Phone:912-690-5735
Mailing Address - Fax:
Practice Address - Street 1:24 JOE KENNEDY BLVD STE 13
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-3113
Practice Address - Country:US
Practice Address - Phone:912-208-2024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-03
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051073736174400000X
ILMG50380121P222Q00000X
1-19-36585103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No174400000XOther Service ProvidersSpecialist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist