Provider Demographics
NPI:1457631962
Name:HARTMAN, NICOLE LEIGH (LCSW)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LEIGH
Last Name:HARTMAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 SIMPSON AVE
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46516-4666
Mailing Address - Country:US
Mailing Address - Phone:574-293-0052
Mailing Address - Fax:574-293-1739
Practice Address - Street 1:236 SIMPSON AVE
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46516-4666
Practice Address - Country:US
Practice Address - Phone:574-293-0052
Practice Address - Fax:574-293-1739
Is Sole Proprietor?:No
Enumeration Date:2011-08-29
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010893371041C0700X
IN34006995A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34006995AOtherLICENSE