Provider Demographics
NPI:1134647779
Name:GORMAN, NICHOLE ANN (MA LPCC)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:ANN
Last Name:GORMAN
Suffix:
Gender:F
Credentials:MA LPCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16003 ESTATE LN
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-2269
Mailing Address - Country:US
Mailing Address - Phone:612-868-1068
Mailing Address - Fax:
Practice Address - Street 1:16003 ESTATE LN
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-2269
Practice Address - Country:US
Practice Address - Phone:612-868-1068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-04
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01607101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional