MEDICARE: NICOLE DOMINE LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	23025	MN
2	1041C0700X	Clinical Social Worker	5293	ND

General Provider Information

NPI Number	:	1396280954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE DOMINE LICSW

Provider Business Mailing Address
First Line	:	4357 13TH AVE S STE 104
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58103-7504
Country	:	US
Telephone Number	:	701-478-4480
Fax Number	:	701-478-4481

Provider Business Practice Location Address
First Line	:	4357 13TH AVE S STE 104
Second Line	:
City	:	FARGO
State	:	ND
Zip	:	58103-7504
Country	:	US
Telephone Number	:	701-478-4480
Fax Number	:	701-478-4481

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/05/2017
Last Update Date	:	11/22/2024

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Directions to “ NICOLE DOMINE LICSW” Practice Location

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