=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962362079
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE M DETRICK NPI
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2025
-----------------------------------------------------
Last Update Date | 11/12/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136 S 9TH ST STE 204
-----------------------------------------------------
City | NOBLESVILLE
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46060-2600
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-401-9919
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14252 AUTUMN WOODS DR
-----------------------------------------------------
City | CARMEL
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46074-8995
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 317-698-3384
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------