Provider Demographics
NPI:1831808534
Name:BUESSE, NICOLE RAE (MA, LPC)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:RAE
Last Name:BUESSE
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17014 NEW COLLEGE AVE STE 206
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1108
Mailing Address - Country:US
Mailing Address - Phone:636-393-8771
Mailing Address - Fax:
Practice Address - Street 1:17014 NEW COLLEGE AVE STE 206
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1108
Practice Address - Country:US
Practice Address - Phone:636-393-8771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021042212101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health