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NPI Code Detail

MEDICARE: NICHOLE R KOTTKE LICSW

MEDICARE: NICHOLE R KOTTKE LICSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker24446MN

General Provider Information

NPI Number : 1457854721
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICHOLE R KOTTKE LICSW
Provider Business Mailing Address
First Line : 615 1ST AVE NE STE 310
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55413-2419
Country : US
Telephone Number : 612-436-0295
Fax Number : 612-436-0163
Provider Business Practice Location Address
First Line : 615 1ST AVE NE STE 310
Second Line :
City : MINNEAPOLIS
State : MN
Zip : 55413-2419
Country : US
Telephone Number : 612-436-0295
Fax Number : 612-436-0163
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/13/2018
Last Update Date : 03/13/2018

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Directions to “ NICHOLE R KOTTKE LICSW” Practice Location

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