Provider Demographics
NPI:1033455704
Name:MALMQUIST, NICOLE MADISON (MSW, LCSW)
Entity Type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:MADISON
Last Name:MALMQUIST
Suffix:
Gender:F
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 NE 10TH TER STE 7
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33909-1713
Mailing Address - Country:US
Mailing Address - Phone:239-777-2419
Mailing Address - Fax:
Practice Address - Street 1:1749 NE 10TH TER STE 7
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33909-1713
Practice Address - Country:US
Practice Address - Phone:239-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-27
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW137111041C0700X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL171M00000XMedicaid