Provider Demographics
NPI:1457854721
Name:KOTTKE, NICHOLE R (LICSW)
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:R
Last Name:KOTTKE
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 1ST AVE NE STE 310
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2419
Mailing Address - Country:US
Mailing Address - Phone:612-436-0295
Mailing Address - Fax:612-436-0163
Practice Address - Street 1:615 1ST AVE NE STE 310
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2419
Practice Address - Country:US
Practice Address - Phone:612-436-0295
Practice Address - Fax:612-436-0163
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN244461041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical