Provider Demographics
NPI:1598146094
Name:MCNICHOLES, PEGGY (MSW, LICSW)
Entity Type:Individual
Prefix:
First Name:PEGGY
Middle Name:
Last Name:MCNICHOLES
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 W LAKE ST
Mailing Address - Street 2:STE 210
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4527
Mailing Address - Country:US
Mailing Address - Phone:612-925-6033
Mailing Address - Fax:612-217-0661
Practice Address - Street 1:3100 W LAKE ST
Practice Address - Street 2:STE 210
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55416-4527
Practice Address - Country:US
Practice Address - Phone:612-925-6033
Practice Address - Fax:612-217-0661
Is Sole Proprietor?:No
Enumeration Date:2015-06-11
Last Update Date:2015-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN107351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical