Provider Demographics
NPI:1891232435
Name:BONGERS, NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BONGERS
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 N HURON ST
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2607
Mailing Address - Country:US
Mailing Address - Phone:734-714-2226
Mailing Address - Fax:
Practice Address - Street 1:47 N HURON ST
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2607
Practice Address - Country:US
Practice Address - Phone:734-714-2226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-20
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA072278104100000X
MI6801099903104100000X
MI6801104881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker