Provider Demographics
NPI:1841526118
Name:RE, NICOLETTE (LCSW, ACSW)
Entity type:Individual
Prefix:MS
First Name:NICOLETTE
Middle Name:
Last Name:RE
Suffix:
Gender:F
Credentials:LCSW, ACSW
Other - Prefix:MS
Other - First Name:SUZANNE
Other - Middle Name:TERRA
Other - Last Name:NICOLETTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW, ACSW
Mailing Address - Street 1:20121 N 76TH ST UNIT 2057
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-3872
Mailing Address - Country:US
Mailing Address - Phone:480-677-1198
Mailing Address - Fax:
Practice Address - Street 1:20121 N 76TH ST UNIT 2057
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-3872
Practice Address - Country:US
Practice Address - Phone:480-677-1198
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-122051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLCSW-12205OtherCLINICAL SOCIAL WORK LICENSE