Provider Demographics
NPI:1285128124
Name:BERENGER, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BERENGER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4346 W ROSE HILL ST STE C
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-5193
Mailing Address - Country:US
Mailing Address - Phone:208-963-8132
Mailing Address - Fax:208-203-0942
Practice Address - Street 1:4346 W ROSE HILL ST STE C
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-5193
Practice Address - Country:US
Practice Address - Phone:208-963-8132
Practice Address - Fax:208-203-0942
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-14
Last Update Date:2022-11-16
Deactivation Date:2022-10-28
Deactivation Code:
Reactivation Date:2022-11-15
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-8203101YP2500X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1285128124Medicaid