Healthcare Provider Details

I. General information

NPI: 1114701349
Provider Name (Legal Business Name): NICOLE BONIN MSW, LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 07/08/2024
Certification Date: 07/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

816 WASHINGTON ST
MANITOWOC WI
54220-4537
US

IV. Provider business mailing address

4555 HARVEST CIR
MANITOWOC WI
54220-9352
US

V. Phone/Fax

Practice location:
  • Phone: 920-645-3743
  • Fax:
Mailing address:
  • Phone: 920-615-5555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number16606
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number11127
License Number StateWI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier11127
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerLICENSED CLINICAL SOCIAL WORKER
# 2
Identifier16606
Identifier TypeOTHER
Identifier StateWI
Identifier IssuerSUBSTANCE ABUSE COUNSELOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: