Provider Demographics
NPI:1588211874
Name:ISBELL, NICOLE BERGAMO (PHD, LP)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:BERGAMO
Last Name:ISBELL
Suffix:
Gender:F
Credentials:PHD, LP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:BERGAMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3005 BOARDWALK ST STE 201
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-5218
Mailing Address - Country:US
Mailing Address - Phone:734-222-9277
Mailing Address - Fax:
Practice Address - Street 1:3005 BOARDWALK ST STE 201
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-5218
Practice Address - Country:US
Practice Address - Phone:734-222-9277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301019415103T00000X, 103TC0700X
MI6362001372103T00000X
MI6351004559103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist