Healthcare Provider Details

I. General information

NPI: 1811845936
Provider Name (Legal Business Name): NICOLE LESLIE OERTEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2026
Last Update Date: 03/17/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4607 NORTH ROAD
CIRCLE PINES MN
55014
US

IV. Provider business mailing address

4707 NORTH ROAD
CIRCLE PINES MN
55014
US

V. Phone/Fax

Practice location:
  • Phone: 763-792-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: