Provider Demographics
NPI:1821396045
Name:BONTRAGER, NICOLE (LPC)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:BONTRAGER
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MRS
Other - First Name:NICCI
Other - Middle Name:
Other - Last Name:BONTRAGER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA, NCC
Mailing Address - Street 1:1315 SAM BASS CIR STE B1
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-4168
Mailing Address - Country:US
Mailing Address - Phone:512-545-0065
Mailing Address - Fax:
Practice Address - Street 1:1315 SAM BASS CIR STE B1
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681-4168
Practice Address - Country:US
Practice Address - Phone:512-545-0065
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX67418101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
251834OtherNATIONAL BOARD OF CERTIFIED COUNSELORS