=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366990996
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE DIANA MADILL-KLUPENGER LCPC 6404
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2016
-----------------------------------------------------
Last Update Date | 06/23/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 687 CAMP NINE RD
-----------------------------------------------------
City | BONNERS FERRY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83805-5074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-314-5734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 687 CAMP NINE RD
-----------------------------------------------------
City | BONNERS FERRY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83805-5074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-314-5734
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | LCPC-6404
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC5539
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------