Healthcare Provider Details

I. General information

NPI: 1366176661
Provider Name (Legal Business Name): NICOLE MARIE FETTIG LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE MYERS

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 02/14/2025
Certification Date: 02/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1237 W DIVIDE AVE STE 5
BISMARCK ND
58501-1208
US

IV. Provider business mailing address

1237 W DIVIDE AVE STE 5
BISMARCK ND
58501-1208
US

V. Phone/Fax

Practice location:
  • Phone: 701-319-7121
  • Fax:
Mailing address:
  • Phone: 701-319-7121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6129
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: