Provider Demographics
NPI:1487008736
Name:NICHOLE MENTZER LCSW PLLC
Entity Type:Organization
Organization Name:NICHOLE MENTZER LCSW PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:M
Authorized Official - Last Name:MENTZER
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:405-201-0620
Mailing Address - Street 1:419 W GRAY ST
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73069-7117
Mailing Address - Country:US
Mailing Address - Phone:405-329-7300
Mailing Address - Fax:405-364-5379
Practice Address - Street 1:1745 NW 16TH ST
Practice Address - Street 2:STE A
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-2067
Practice Address - Country:US
Practice Address - Phone:405-201-0620
Practice Address - Fax:405-364-5379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK54441041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty