Healthcare Provider Details

I. General information

NPI: 1063014801
Provider Name (Legal Business Name): NICOLE ZLATE MA, LPCC, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2020
Last Update Date: 11/09/2023
Certification Date: 10/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2006 1ST AVE STE 201
ANOKA MN
55303-2255
US

IV. Provider business mailing address

1902 5TH AVE STE 4
ANOKA MN
55303-2692
US

V. Phone/Fax

Practice location:
  • Phone: 763-647-8188
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3399
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number306627
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: