Healthcare Provider Details

I. General information

NPI: 1336892686
Provider Name (Legal Business Name): NICOLE BERENGER COUNSELING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2022
Last Update Date: 10/28/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4346 W ROSE HILL ST STE C
BOISE ID
83705-5193
US

IV. Provider business mailing address

4346 W ROSE HILL ST STE C
BOISE ID
83705-5193
US

V. Phone/Fax

Practice location:
  • Phone: 208-963-8132
  • Fax: 208-203-0942
Mailing address:
  • Phone: 208-963-8132
  • Fax: 208-203-0942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: NICOLE BERENGER
Title or Position: LCPC
Credential:
Phone: 208-963-8132