Provider Demographics
NPI:1790916278
Name:GUSTAFSON-BINGER, NICOLE VIENNA (LPC)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:VIENNA
Last Name:GUSTAFSON-BINGER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5606 EAGLE POINT DR
Mailing Address - Street 2:
Mailing Address - City:RACINE
Mailing Address - State:WI
Mailing Address - Zip Code:53406-1181
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4109 67TH ST
Practice Address - Street 2:
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53142-3836
Practice Address - Country:US
Practice Address - Phone:262-652-9830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-02
Last Update Date:2009-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4197-125101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional