Healthcare Provider Details

I. General information

NPI: 1043713282
Provider Name (Legal Business Name): NICOLE DOROTHY WATSON MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE DOROTHY LOUKES MSW, ASW, LGSW

II. Dates (important events)

Enumeration Date: 03/14/2018
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date: 10/11/2019
Reactivation Date: 01/24/2020

III. Provider practice location address

394 S LAKE AVE STE 515
DULUTH MN
55802-2325
US

IV. Provider business mailing address

394 S LAKE AVE STE 515
DULUTH MN
55802-2325
US

V. Phone/Fax

Practice location:
  • Phone: 218-206-6676
  • Fax:
Mailing address:
  • Phone: 218-206-6676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number79699
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number21967
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: