Provider Demographics
NPI:1174109367
Name:BERNARD, NICOLE RENEE (LPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:BERNARD
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 RUSSO TER
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4054
Mailing Address - Country:US
Mailing Address - Phone:203-526-2279
Mailing Address - Fax:
Practice Address - Street 1:45 RUSSO TER
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4054
Practice Address - Country:US
Practice Address - Phone:203-526-2279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-19
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004547101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional