Provider Demographics
NPI:1790223162
Name:ROBERTS, NICOLE LEA (LMFT, LCPC, PMH-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LEA
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:LMFT, LCPC, PMH-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4273 44TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-3939
Mailing Address - Country:US
Mailing Address - Phone:701-526-4885
Mailing Address - Fax:
Practice Address - Street 1:4273 44TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-3939
Practice Address - Country:US
Practice Address - Phone:701-526-4885
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-06
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND2015-051106H00000X
MN3473106H00000X
MTBBH-LCPC-LIC-29694101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist