Provider Demographics
NPI:1467687426
Name:LORE, NICOLE LEA (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEA
Last Name:LORE
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 1:254 E GOLD DUST WAY
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85243-5884
Mailing Address - Country:US
Mailing Address - Phone:480-326-7215
Mailing Address - Fax:
Practice Address - Street 1:20185 E OCOTILLO RD STE 105
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85242-7663
Practice Address - Country:US
Practice Address - Phone:480-987-2700
Practice Address - Fax:480-987-2703
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-125871041C0700X
MELC113291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical