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General NPI Number Information
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NPI Number | 1609214311
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Entity Type | Organization
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Legal Business Name | SUSAN E NICOL PHD LLC
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Dates
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Enumeration Date | 06/05/2013
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Last Update Date | 06/05/2013
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Provider Practice Location Address
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Address Line | 4500 PARK GLEN RD SUITE 270
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City | ST LOUIS PARK
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State | MN
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Zip | 55416-4871
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Country | US
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Telephone | 952-929-9478
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Fax | 952-929-9548
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Provider Business Mailing Address
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Address Line | 4500 PARK GLEN RD SUITE 270
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City | ST LOUIS PARK
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State | MN
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Zip | 55416-4871
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Country | US
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Telephone | 952-929-9478
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Fax | 952-929-9548
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | SUSAN E NICOL
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Credential | PHD
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Telephone | 952-929-9478
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | LP0182
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License Number State | MN
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