Provider Demographics
NPI:1477823086
Name:GUDENSCHWAGER, NIKKI LEE
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:LEE
Last Name:GUDENSCHWAGER
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 1:4 BOODY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2105
Mailing Address - Country:US
Mailing Address - Phone:207-245-0133
Mailing Address - Fax:
Practice Address - Street 1:50 MOODY ST
Practice Address - Street 2:
Practice Address - City:SACO
Practice Address - State:ME
Practice Address - Zip Code:04072-1536
Practice Address - Country:US
Practice Address - Phone:207-294-4414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-12
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEXL3834101YM0800X
WI1636-226101YP2500X
MECC4325101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1636-226OtherPROFESSIONAL COUNSELING TRAINING LICENSE NUMBER