Provider Demographics
NPI:1417475948
Name:KRZAN, NICOLE GAMUN HO (MS, LPC, ATR)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:GAMUN HO
Last Name:KRZAN
Suffix:
Gender:F
Credentials:MS, LPC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 THAMES VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29642-1674
Mailing Address - Country:US
Mailing Address - Phone:757-687-9981
Mailing Address - Fax:
Practice Address - Street 1:GATEWAY COUNSELING
Practice Address - Street 2:126 BROADBENT WAY
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29625
Practice Address - Country:US
Practice Address - Phone:864-406-6041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI101YM0800X
103K00000X
SC8072101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1417475948Medicaid