Healthcare Provider Details

I. General information

NPI: 1205487980
Provider Name (Legal Business Name): NICOLE KAUL MSW, LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2019
Last Update Date: 04/30/2020
Certification Date: 04/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1405 LILAC DR N STE 151
GOLDEN VALLEY MN
55422-4536
US

IV. Provider business mailing address

3322 15TH AVE S APT 2
MINNEAPOLIS MN
55407-7209
US

V. Phone/Fax

Practice location:
  • Phone: 763-525-1746
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number25444
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: