Provider Demographics
NPI:1174381909
Name:WEISGERBER, NICOLE MEGAN (CDAC1)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MEGAN
Last Name:WEISGERBER
Suffix:
Gender:F
Credentials:CDAC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 JUDY LN
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40505-1715
Mailing Address - Country:US
Mailing Address - Phone:185-920-2498
Mailing Address - Fax:
Practice Address - Street 1:1093 S BROADWAY STE 1218
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-2677
Practice Address - Country:US
Practice Address - Phone:859-202-4983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-07
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY286964101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)