Provider Demographics
NPI:1841746146
Name:DIERCKS, NICOLE MARIE (LPC, CSAC, CCTP-II)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:DIERCKS
Suffix:
Gender:F
Credentials:LPC, CSAC, CCTP-II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7969 ASHTON AVE
Mailing Address - Street 2:
Mailing Address - City:MANASSAS
Mailing Address - State:VA
Mailing Address - Zip Code:20109-2885
Mailing Address - Country:US
Mailing Address - Phone:703-792-4175
Mailing Address - Fax:703-792-7817
Practice Address - Street 1:7969 ASHTON AVE
Practice Address - Street 2:
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20109-2885
Practice Address - Country:US
Practice Address - Phone:703-792-4175
Practice Address - Fax:703-792-7817
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6995-125101YA0400X, 101YM0800X
VA0701008933101Y00000X
VA0710103493101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA14378296Medicaid
WI1295228120Medicaid