Provider Demographics
NPI:1669296042
Name:WEGNER, NICOLE M (MSW, LICSW, APSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:WEGNER
Suffix:
Gender:F
Credentials:MSW, LICSW, APSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:IMMERFALL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1401 EAST 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2407
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-302-8698
Practice Address - Street 1:120 W 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55802-2017
Practice Address - Country:US
Practice Address - Phone:218-728-4491
Practice Address - Fax:218-302-8698
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1340231041C0700X
MN310011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical