Provider Demographics
NPI:1063833457
Name:GUDINO, NICOLAS JR
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:GUDINO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W MARKET ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-3918
Mailing Address - Country:US
Mailing Address - Phone:309-827-5351
Mailing Address - Fax:
Practice Address - Street 1:108 W MARKET ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3918
Practice Address - Country:US
Practice Address - Phone:309-827-5351
Practice Address - Fax:309-829-6808
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-02
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180010615101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health