Provider Demographics
NPI:1609214311
Name:SUSAN E NICOL PHD LLC
Entity Type:Organization
Organization Name:SUSAN E NICOL PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:NICOL
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:952-929-9478
Mailing Address - Street 1:4500 PARK GLEN RD
Mailing Address - Street 2:SUITE 270
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4871
Mailing Address - Country:US
Mailing Address - Phone:952-929-9478
Mailing Address - Fax:952-929-9548
Practice Address - Street 1:4500 PARK GLEN RD
Practice Address - Street 2:SUITE 270
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4871
Practice Address - Country:US
Practice Address - Phone:952-929-9478
Practice Address - Fax:952-929-9548
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-05
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP0182103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN424352800Medicaid