Provider Demographics
NPI:1497151385
Name:SHAFFER, NICOLE M
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SHAFFER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:CALDWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, LMFT
Mailing Address - Street 1:2369 109TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-4156
Mailing Address - Country:US
Mailing Address - Phone:763-506-2800
Mailing Address - Fax:
Practice Address - Street 1:2369 109TH AVE NW
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-4156
Practice Address - Country:US
Practice Address - Phone:763-506-2800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1901106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist