Provider Demographics
NPI:1225774029
Name:LOVE, NICOLE MARIE (LSAA, LMSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:LOVE
Suffix:
Gender:F
Credentials:LSAA, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 8TH ST NE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-0502
Mailing Address - Country:US
Mailing Address - Phone:505-720-0877
Mailing Address - Fax:
Practice Address - Street 1:405 8TH ST NE
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-0502
Practice Address - Country:US
Practice Address - Phone:505-720-0877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCTB-2022-0144101YA0400X
NMSWB-2022-1184101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMCTB-2022-0144OtherLICENSED SUBSTANCE ABUSE ASSOCIATE
NMSWB-2022-1184OtherLICENSED MASTER SOCIAL WORKER