Provider Demographics
NPI:1164711958
Name:KONEN, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:KONEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S ALMON ST
Mailing Address - Street 2:SUITE #204
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843-2098
Mailing Address - Country:US
Mailing Address - Phone:208-310-4578
Mailing Address - Fax:
Practice Address - Street 1:200 S ALMON ST
Practice Address - Street 2:SUITE #204
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-2098
Practice Address - Country:US
Practice Address - Phone:208-310-4578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-01
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC946101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health