Provider Demographics
NPI:1619298916
Name:STEPHENS, NICHOLAS WILLIAM (LICSW)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:WILLIAM
Last Name:STEPHENS
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 PARK ST
Mailing Address - Street 2:#5
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55103-1869
Mailing Address - Country:US
Mailing Address - Phone:612-363-4284
Mailing Address - Fax:
Practice Address - Street 1:8401 WAYZATA BLVD
Practice Address - Street 2:#370
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55426-1343
Practice Address - Country:US
Practice Address - Phone:763-544-1006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-21
Last Update Date:2010-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN180871041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical