Provider Demographics
NPI:1053642587
Name:MICHAELSON, NICOLE R
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:R
Last Name:MICHAELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 LANDMARK DR
Mailing Address - Street 2:STE380/CPD
Mailing Address - City:BELLEVUE
Mailing Address - State:KY
Mailing Address - Zip Code:41073-1393
Mailing Address - Country:US
Mailing Address - Phone:859-392-3829
Mailing Address - Fax:859-392-3966
Practice Address - Street 1:103 LANDMARK DR
Practice Address - Street 2:STE380/CPD
Practice Address - City:BELLEVUE
Practice Address - State:KY
Practice Address - Zip Code:41073-1393
Practice Address - Country:US
Practice Address - Phone:859-392-3829
Practice Address - Fax:859-392-3966
Is Sole Proprietor?:No
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 00097911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical