Provider Demographics
NPI:1497731145
Name:BROGNA, NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BROGNA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 BROAD ST # 9
Mailing Address - Street 2:
Mailing Address - City:STROUDSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:18360-1590
Mailing Address - Country:US
Mailing Address - Phone:570-872-9323
Mailing Address - Fax:570-872-9325
Practice Address - Street 1:134 BROAD ST # 9
Practice Address - Street 2:
Practice Address - City:STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18360-1590
Practice Address - Country:US
Practice Address - Phone:570-872-9323
Practice Address - Fax:570-872-9325
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0134261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
2106029OtherCIGNA BEHAVIORAL HEALTH
4205090000OtherMAGELLAN HEALTH
PA07796656Medicaid
4205090000OtherMAGELLAN HEALTH