Provider Demographics
NPI:1487191607
Name:MUZZY, NICOLE (MA, LMFT, LADC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MUZZY
Suffix:
Gender:F
Credentials:MA, LMFT, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3025 SILVER LAKE RD NE
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:MN
Mailing Address - Zip Code:55418
Mailing Address - Country:US
Mailing Address - Phone:651-285-6363
Mailing Address - Fax:
Practice Address - Street 1:3025 SILVER LAKE RD NE
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:MN
Practice Address - Zip Code:55418-2435
Practice Address - Country:US
Practice Address - Phone:651-285-6363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-25
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN303244101YA0400X
MN3758101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)