Provider Demographics
NPI:1851838635
Name:MANK, NICOLE (LCSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MANK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BARBOUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:398 HINKS RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:ME
Mailing Address - Zip Code:04348-4012
Mailing Address - Country:US
Mailing Address - Phone:207-557-0395
Mailing Address - Fax:
Practice Address - Street 1:398 HINKS RD
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:ME
Practice Address - Zip Code:04348-4012
Practice Address - Country:US
Practice Address - Phone:207-557-0395
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-31
Last Update Date:2019-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMC16510104100000X
MELC178251041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
1851838635OtherNPI