Healthcare Provider Details

I. General information

NPI: 1689184079
Provider Name (Legal Business Name): NICOLE MARIE-ANGE OVERBY LMFT, LADC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2017
Last Update Date: 08/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14040 NORTHDALE BLVD STE 100
ROGERS MN
55374-9612
US

IV. Provider business mailing address

1160 LAKE ST N
BIG LAKE MN
55309-9499
US

V. Phone/Fax

Practice location:
  • Phone: 763-488-4100
  • Fax: 763-488-4105
Mailing address:
  • Phone: 320-282-3528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number304650
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3404
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: