Provider Demographics
NPI:1760853386
Name:GAEDTKE, NICOLE (MSED, LMFT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GAEDTKE
Suffix:
Gender:F
Credentials:MSED, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5651 COVENTRY LN # 112
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7145
Mailing Address - Country:US
Mailing Address - Phone:260-205-8644
Mailing Address - Fax:
Practice Address - Street 1:2201 CEDAR RIDGE COVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818
Practice Address - Country:US
Practice Address - Phone:260-205-8644
Practice Address - Fax:260-265-1706
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-08
Last Update Date:2022-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN35001980A106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist