Provider Demographics
NPI:1366990996
Name:MADILL-KLUPENGER, NICOLE DIANA (LCPC 6404)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DIANA
Last Name:MADILL-KLUPENGER
Suffix:
Gender:F
Credentials:LCPC 6404
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DIANA
Other - Last Name:KLUPENGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC 6404
Mailing Address - Street 1:687 CAMP NINE RD
Mailing Address - Street 2:
Mailing Address - City:BONNERS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83805-5074
Mailing Address - Country:US
Mailing Address - Phone:541-314-5734
Mailing Address - Fax:
Practice Address - Street 1:687 CAMP NINE RD
Practice Address - Street 2:
Practice Address - City:BONNERS FERRY
Practice Address - State:ID
Practice Address - Zip Code:83805-5074
Practice Address - Country:US
Practice Address - Phone:541-314-5734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC-6404101YM0800X
IDLPC5539101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional