Healthcare Provider Details

I. General information

NPI: 1225357213
Provider Name (Legal Business Name): NICOLE JOY VATTERRODT LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2010
Last Update Date: 06/07/2023
Certification Date: 06/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13403 N GOVERNMENT WAY STE 319
HAYDEN ID
83835-8905
US

IV. Provider business mailing address

13403 N GOVERNMENT WAY STE 319
HAYDEN ID
83835-8905
US

V. Phone/Fax

Practice location:
  • Phone: 480-980-5703
  • Fax:
Mailing address:
  • Phone: 480-980-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-36982
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLMSW-30540
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: