Provider Demographics
NPI:1871061465
Name:BLOMBERG, NICOLE KAY (LCMFT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:KAY
Last Name:BLOMBERG
Suffix:
Gender:F
Credentials:LCMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 W DOUGLAS AVE STE 555
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67202-3007
Mailing Address - Country:US
Mailing Address - Phone:316-570-1995
Mailing Address - Fax:
Practice Address - Street 1:200 W DOUGLAS AVE STE 555
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-3007
Practice Address - Country:US
Practice Address - Phone:316-665-4710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-13
Last Update Date:2022-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS3046106H00000X
KS3047106H00000X
KS3019106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist