Provider Demographics
NPI:1326679119
Name:REITSMA, NICOLE ELIZABETH (LICSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ELIZABETH
Last Name:REITSMA
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ELIZABETH
Other - Last Name:STEPAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LICSW
Mailing Address - Street 1:2550 UNIVERSITY AVE W STE 110N
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55114-2001
Mailing Address - Country:US
Mailing Address - Phone:651-602-5311
Mailing Address - Fax:651-222-6786
Practice Address - Street 1:910 E 26TH ST STE 100-200
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4526
Practice Address - Country:US
Practice Address - Phone:128-846-3006
Practice Address - Fax:612-884-6363
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-30
Last Update Date:2020-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN235501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical