Provider Demographics
NPI:1841917614
Name:CAMPBELL, NICOLE (MSW, LICSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MSW, LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 RICHFIELD PKWY APT 214
Mailing Address - Street 2:
Mailing Address - City:RICHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55423-7507
Mailing Address - Country:US
Mailing Address - Phone:763-238-2076
Mailing Address - Fax:
Practice Address - Street 1:8011 34TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55425-1637
Practice Address - Country:US
Practice Address - Phone:612-283-0914
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-24
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN29053101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health