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General NPI Number Information
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NPI Number | 1205493145
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Entity Type | Individual
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Provider Name | NICHOLE M SURBAUGH LMHCA
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Gender | Female
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Dates
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Enumeration Date | 05/28/2019
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Last Update Date | 05/28/2019
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Provider Practice Location Address
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Address Line | 2350 S STATE ROAD 1
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City | BLUFFTON
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State | IN
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Zip | 46714-9698
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Country | US
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Telephone | 260-307-5030
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Fax | 260-824-8445
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Provider Business Mailing Address
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Address Line | 2350 S STATE ROAD 1
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City | BLUFFTON
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State | IN
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Zip | 46714-9698
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Country | US
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Telephone | 260-307-5030
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Fax | 260-824-8445
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 88000477A
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License Number State | IN
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