Provider Demographics
NPI:1730487687
Name:BOBERG, NICHOL A (MED, PCC-S)
Entity type:Individual
Prefix:
First Name:NICHOL
Middle Name:A
Last Name:BOBERG
Suffix:
Gender:F
Credentials:MED, PCC-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 LAKEVIEW DR UNIT 206
Mailing Address - Street 2:
Mailing Address - City:WILDER
Mailing Address - State:KY
Mailing Address - Zip Code:41071-5310
Mailing Address - Country:US
Mailing Address - Phone:859-816-7475
Mailing Address - Fax:
Practice Address - Street 1:400 LAKEVIEW DR UNIT 206
Practice Address - Street 2:
Practice Address - City:WILDER
Practice Address - State:KY
Practice Address - Zip Code:41071-5310
Practice Address - Country:US
Practice Address - Phone:859-816-7475
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-02
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1268101YP2500X
OHE.8044-SUPV101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional