Healthcare Provider Details

I. General information

NPI: 1831808534
Provider Name (Legal Business Name): NICOLE RAE BUESSE MA, LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2022
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17014 NEW COLLEGE AVE STE 206
WILDWOOD MO
63040-1108
US

IV. Provider business mailing address

17014 NEW COLLEGE AVE STE 206
WILDWOOD MO
63040-1108
US

V. Phone/Fax

Practice location:
  • Phone: 636-393-8771
  • Fax:
Mailing address:
  • Phone: 636-393-8771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number2021042212
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: