Provider Demographics
NPI:1689184079
Name:OVERBY, NICOLE MARIE-ANGE (LMFT, LADC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE-ANGE
Last Name:OVERBY
Suffix:
Gender:F
Credentials:LMFT, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1160 LAKE ST N
Mailing Address - Street 2:
Mailing Address - City:BIG LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55309-9499
Mailing Address - Country:US
Mailing Address - Phone:320-282-3528
Mailing Address - Fax:
Practice Address - Street 1:14040 NORTHDALE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9612
Practice Address - Country:US
Practice Address - Phone:763-488-4100
Practice Address - Fax:763-488-4105
Is Sole Proprietor?:No
Enumeration Date:2017-10-11
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304650101YA0400X
MN3404106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)