Healthcare Provider Details

I. General information

NPI: 1881312940
Provider Name (Legal Business Name): NICOLE RAE OTHER MEDICINE MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2022
Last Update Date: 08/16/2022
Certification Date: 08/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4354 BRADDOCK TRL
EAGAN MN
55123-1980
US

IV. Provider business mailing address

4354 BRADDOCK TRL
EAGAN MN
55123-1980
US

V. Phone/Fax

Practice location:
  • Phone: 651-340-5785
  • Fax:
Mailing address:
  • Phone: 651-340-5785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number19286
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: