Provider Demographics
NPI:1457693459
Name:HARRIMAN, NICOLE LEE (LICSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEE
Last Name:HARRIMAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4884 MILLER TRUNK HWY STE 100
Mailing Address - Street 2:
Mailing Address - City:HERMANTOWN
Mailing Address - State:MN
Mailing Address - Zip Code:55811-2836
Mailing Address - Country:US
Mailing Address - Phone:218-812-3600
Mailing Address - Fax:218-309-0198
Practice Address - Street 1:4884 MILLER TRUNK HWY STE 100
Practice Address - Street 2:
Practice Address - City:HERMANTOWN
Practice Address - State:MN
Practice Address - Zip Code:55811-2836
Practice Address - Country:US
Practice Address - Phone:218-812-3600
Practice Address - Fax:218-309-0198
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-18
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN213751041C0700X, 104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1457693459Medicaid
MN1457693459OtherUBH-MEDICA
MN1457693459Medicaid