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General NPI Number Information
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NPI Number | 1790916278
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Entity Type | Individual
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Provider Name | NICOLE VIENNA GUSTAFSON-BINGER L.P.C.
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Gender | Female
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Dates
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Enumeration Date | 08/02/2009
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Last Update Date | 08/02/2009
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Provider Practice Location Address
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Address Line | 4109 67TH ST
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City | KENOSHA
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State | WI
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Zip | 53142-3836
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Country | US
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Telephone | 262-652-9830
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Fax |
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Provider Business Mailing Address
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Address Line | 5606 EAGLE POINT DR
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City | RACINE
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State | WI
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Zip | 53406-1181
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Country | US
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Telephone |
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Fax |
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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 | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 4197-125
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License Number State | WI
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