Healthcare Provider Details

I. General information

NPI: 1003241555
Provider Name (Legal Business Name): NICOLE RENEE CONKLIN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2013
Last Update Date: 07/15/2022
Certification Date: 07/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG 700
VILSECK BAYERN
92249
DE

IV. Provider business mailing address

CMR 411 BOX 5555
APO AE
09112-0056
US

V. Phone/Fax

Practice location:
  • Phone: 314-590-2387
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number09923138
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: