Provider Demographics
NPI:1558886382
Name:WIEBERDINK, NIKKI RAE
Entity Type:Individual
Prefix:
First Name:NIKKI
Middle Name:RAE
Last Name:WIEBERDINK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 1ST ST N STE 101
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1924
Mailing Address - Country:US
Mailing Address - Phone:320-202-2024
Mailing Address - Fax:
Practice Address - Street 1:3333 W DIVISION ST STE 209
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4322
Practice Address - Country:US
Practice Address - Phone:320-253-5555
Practice Address - Fax:320-529-1976
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCC01194101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional