Provider Demographics
NPI:1194324343
Name:HARDENBURGH, NICOLE DORIO (PHD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DORIO
Last Name:HARDENBURGH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:BETHANY
Other - Last Name:DORIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:USA MEDDAC
Mailing Address - Street 2:11050 MOUNT BELVEDERE BLVD.
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602
Mailing Address - Country:US
Mailing Address - Phone:315-772-6184
Mailing Address - Fax:
Practice Address - Street 1:USA MEDDAC
Practice Address - Street 2:11050 MT. BELVEDERE BLVD.
Practice Address - City:FORT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-772-6184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-20
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020029140103T00000X
NY025392-01103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO490089658Medicaid
MO824000481OtherPHD