Provider Demographics
NPI:1740505460
Name:LIEDTKE, NICOLE MARIE (LCSW, LCAC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:LIEDTKE
Suffix:
Gender:F
Credentials:LCSW, LCAC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, LCAC
Mailing Address - Street 1:3645 N BRIARWOOD LN
Mailing Address - Street 2:STE A
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47304-5337
Mailing Address - Country:US
Mailing Address - Phone:765-289-5520
Mailing Address - Fax:765-289-5840
Practice Address - Street 1:14074 TRADE CENTER DR
Practice Address - Street 2:STE 220
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46038-4575
Practice Address - Country:US
Practice Address - Phone:317-775-7797
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-06
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001005A101YA0400X
IN34005950A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001111107OtherANTHEM BLUE CROSS BLUE SHIELD
IN34005950AOtherLCSW