Healthcare Provider Details

I. General information

NPI: 1336085620
Provider Name (Legal Business Name): NICOLE MARIE BOHNETT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2026
Last Update Date: 04/28/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45154 UNDERWOOD LN
STERLING VA
20166-2300
US

IV. Provider business mailing address

20362 FLUSHING MEADOWS CT
ASHBURN VA
20147-3854
US

V. Phone/Fax

Practice location:
  • Phone: 301-767-1733
  • Fax:
Mailing address:
  • Phone: 703-628-2584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: