Healthcare Provider Details

I. General information

NPI: 1649808163
Provider Name (Legal Business Name): NICOLE BEBIAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7595 ROYAL FERN LN
NOBLESVILLE IN
46062-6617
US

IV. Provider business mailing address

7595 ROYAL FERN LN
NOBLESVILLE IN
46062-6617
US

V. Phone/Fax

Practice location:
  • Phone: 623-521-0149
  • Fax:
Mailing address:
  • Phone: 623-521-0149
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number180004686
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: