Healthcare Provider Details

I. General information

NPI: 1265743900
Provider Name (Legal Business Name): NICOLE LINDBERG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE LECLAIR

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 W BROADWAY AVE
FOREST LAKE MN
55025-1402
US

IV. Provider business mailing address

407 W BROADWAY AVE
FOREST LAKE MN
55025-1402
US

V. Phone/Fax

Practice location:
  • Phone: 612-236-8994
  • Fax:
Mailing address:
  • Phone: 612-236-8994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number35038
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number307413
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: