Provider Demographics
NPI:1750151502
Name:CRONQUIST, NICOLE ANN (LPCA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:CRONQUIST
Suffix:
Gender:F
Credentials:LPCA
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANN
Other - Last Name:GLENN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPCA
Mailing Address - Street 1:455 LAKESHORE PKWY
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-4205
Mailing Address - Country:US
Mailing Address - Phone:803-909-6363
Mailing Address - Fax:
Practice Address - Street 1:455 LAKESHORE PKWY
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29730-4205
Practice Address - Country:US
Practice Address - Phone:803-909-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
SC8933101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)