Provider Demographics
NPI:1427408566
Name:BONCK, NICK (CAC II)
Entity Type:Individual
Prefix:MR
First Name:NICK
Middle Name:
Last Name:BONCK
Suffix:
Gender:M
Credentials:CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8160 PIUTE RD LOT 166
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80926-9751
Mailing Address - Country:US
Mailing Address - Phone:719-502-9797
Mailing Address - Fax:
Practice Address - Street 1:8160 PIUTE RD LOT 166
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80926-9751
Practice Address - Country:US
Practice Address - Phone:719-502-9797
Practice Address - Fax:719-275-4209
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACB 7810101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)