Provider Demographics
NPI:1477201465
Name:OWENBURG, NICOLE LYNN (LAC, NCC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:OWENBURG
Suffix:
Gender:F
Credentials:LAC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 WINTERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:BRICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08723-5541
Mailing Address - Country:US
Mailing Address - Phone:323-205-2487
Mailing Address - Fax:
Practice Address - Street 1:22 VILLAGE CT
Practice Address - Street 2:
Practice Address - City:HAZLET
Practice Address - State:NJ
Practice Address - Zip Code:07730-1532
Practice Address - Country:US
Practice Address - Phone:732-639-0232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-17
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00630900101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health