Provider Demographics
NPI:1033728357
Name:BORDEAUX-COLLINS, SHENIKA NICOLE (LAC, LADC)
Entity Type:Individual
Prefix:
First Name:SHENIKA
Middle Name:NICOLE
Last Name:BORDEAUX-COLLINS
Suffix:
Gender:F
Credentials:LAC, LADC
Other - Prefix:
Other - First Name:SHENIKA
Other - Middle Name:
Other - Last Name:BORDEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1602 35TH ST S APT 15
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-8420
Mailing Address - Country:US
Mailing Address - Phone:701-261-2455
Mailing Address - Fax:701-532-1447
Practice Address - Street 1:1602 35TH ST S APT 15
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-8420
Practice Address - Country:US
Practice Address - Phone:701-261-2455
Practice Address - Fax:701-532-1447
Is Sole Proprietor?:No
Enumeration Date:2020-07-23
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 171M00000X
MN304585101YM0800X
ND1800101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health