Provider Demographics
NPI:1396518031
Name:GORNOWICZ, NICOLE (LPCC, ATR)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GORNOWICZ
Suffix:
Gender:F
Credentials:LPCC, ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1917 ARTHUR ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4705
Mailing Address - Country:US
Mailing Address - Phone:612-718-2389
Mailing Address - Fax:
Practice Address - Street 1:2001 BEAM AVE
Practice Address - Street 2:
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1401
Practice Address - Country:US
Practice Address - Phone:952-737-4520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-03
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN221700000X
MNCC03409101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist