Provider Demographics
NPI:1073636932
Name:MEYER, CONNIE NICHOLS (MA)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:NICHOLS
Last Name:MEYER
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3206 W OWASSO BLVD
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-4138
Mailing Address - Country:US
Mailing Address - Phone:651-490-9891
Mailing Address - Fax:
Practice Address - Street 1:3206 W OWASSO BLVD
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-4138
Practice Address - Country:US
Practice Address - Phone:651-490-9891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3999103TC1900X
MN1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical