Provider Demographics
NPI:1902590847
Name:BOGUE, NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BOGUE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4310 METRO PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-9416
Mailing Address - Country:US
Mailing Address - Phone:239-236-8784
Mailing Address - Fax:239-790-2624
Practice Address - Street 1:285 CLYDE MORRIS BLVD STE 300
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-8144
Practice Address - Country:US
Practice Address - Phone:386-262-1627
Practice Address - Fax:386-262-1628
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW213501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical