Provider Demographics
NPI:1215206552
Name:SMITH, NICOLE LYNN (PSYD, LP)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LYNN
Last Name:SMITH
Suffix:
Gender:F
Credentials:PSYD, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2841 BRYANT AVE S APT 130
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-4896
Mailing Address - Country:US
Mailing Address - Phone:414-232-7277
Mailing Address - Fax:
Practice Address - Street 1:10273 YELLOW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9144
Practice Address - Country:US
Practice Address - Phone:952-215-3759
Practice Address - Fax:952-401-9805
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-15
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP5504103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent