Healthcare Provider Details

I. General information

NPI: 1831406537
Provider Name (Legal Business Name): NICOLE LEE CLOVER LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2010
Last Update Date: 09/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 E 2ND ST
DULUTH MN
55805-1913
US

IV. Provider business mailing address

1420 LONDON RD STE 204
DULUTH MN
55805-2422
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-5360
  • Fax: 218-727-1167
Mailing address:
  • Phone: 218-786-5360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number20049
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: