Provider Demographics
NPI:1295968717
Name:GREGORY, NICHOLE BONNIE (LADC LICENSE ALC)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:BONNIE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:LADC LICENSE ALC
Other - Prefix:
Other - First Name:NICHOLE
Other - Middle Name:BONNIE
Other - Last Name:SWANSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PLADC PROVISION
Mailing Address - Street 1:2170 NORTH PLATTE STREET
Mailing Address - Street 2:AWARENESS COUNSELING
Mailing Address - City:FREMONT
Mailing Address - State:NE
Mailing Address - Zip Code:68025-2630
Mailing Address - Country:US
Mailing Address - Phone:402-753-6440
Mailing Address - Fax:402-753-6445
Practice Address - Street 1:2170 NORTH PLATTE STREET
Practice Address - Street 2:AWARENESS COUNSELING
Practice Address - City:FREMONT
Practice Address - State:NE
Practice Address - Zip Code:68025-2630
Practice Address - Country:US
Practice Address - Phone:402-753-6440
Practice Address - Fax:402-753-6445
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NEP658103K00000X
NE857101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
13947938OtherCAQH
13947938OtherCAQH