Healthcare Provider Details

I. General information

NPI: 1568115566
Provider Name (Legal Business Name): NICOLE LEE MALECEK MPS LPCC LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2022
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 CHURCH ST SE
MINNEAPOLIS MN
55455-0222
US

IV. Provider business mailing address

410 CHURCH ST SE
MINNEAPOLIS MN
55455-0222
US

V. Phone/Fax

Practice location:
  • Phone: 612-624-1444
  • Fax: 612-677-3211
Mailing address:
  • Phone: 612-624-1444
  • Fax: 612-677-3211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number3071
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: