Provider Demographics
NPI:1184403016
Name:BOSSAK, NICOLE (LPCA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:
Last Name:BOSSAK
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 WHITE HERON DR
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29907-1849
Mailing Address - Country:US
Mailing Address - Phone:631-275-3561
Mailing Address - Fax:
Practice Address - Street 1:25 CLARK SUMMIT DR STE 103
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-4200
Practice Address - Country:US
Practice Address - Phone:843-405-9479
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-28
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8478101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional