Provider Demographics
NPI:1740923721
Name:NIKKI RAE LLC
Entity type:Organization
Organization Name:NIKKI RAE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:NIKKI
Authorized Official - Middle Name:
Authorized Official - Last Name:ROTH
Authorized Official - Suffix:
Authorized Official - Credentials:LPC-MH,, LPCC, LAC,
Authorized Official - Phone:605-403-4167
Mailing Address - Street 1:3500 S PHILLIPS AVE STE 241
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57105-6863
Mailing Address - Country:US
Mailing Address - Phone:605-403-4167
Mailing Address - Fax:
Practice Address - Street 1:3500 S PHILLIPS AVE STE 241
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57105-6863
Practice Address - Country:US
Practice Address - Phone:605-403-4167
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-04-18
Last Update Date:2022-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)