Provider Demographics
NPI:1699354571
Name:GEROGEORGE, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GEROGEORGE
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 1:10273 YELLOW CIRCLE DR
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55343-9144
Mailing Address - Country:US
Mailing Address - Phone:952-401-9359
Mailing Address - Fax:
Practice Address - Street 1:10273 YELLOW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9144
Practice Address - Country:US
Practice Address - Phone:612-746-7270
Practice Address - Fax:612-509-6689
Is Sole Proprietor?:No
Enumeration Date:2021-04-07
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician