Provider Demographics
NPI:1841746146
Name:DIERCKS, NICOLE MARIE (LPC, CSAC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:DIERCKS
Suffix:
Gender:
Credentials:LPC, CSAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 OLD MACK RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37040-8338
Mailing Address - Country:US
Mailing Address - Phone:512-887-2862
Mailing Address - Fax:
Practice Address - Street 1:950 OLD MACK RD
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37040-8338
Practice Address - Country:US
Practice Address - Phone:512-887-2862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-28
Last Update Date:2025-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0701008933101Y00000X, 101Y00000X
WI16382-132101YA0400X
WI6995-125101YM0800X
101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1295228120Medicaid
VA14378296Medicaid