Healthcare Provider Details

I. General information

NPI: 1477381713
Provider Name (Legal Business Name): NICOLE BETH PETRICH LPC, LPC-MH, ACS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 E 26TH ST
SIOUX FALLS SD
57103-4187
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 605-328-9000
  • Fax:
Mailing address:
  • Phone: 605-328-9419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-MH30508
License Number StateSD
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC7132
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: