MEDICARE: NICOLE MUZZY MA, LMFT, LADC

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	303244	MN
2	101YM0800X	Mental Health Counselor	3758	MN

General Provider Information

NPI Number	:	1487191607
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MUZZY MA, LMFT, LADC

Provider Business Mailing Address
First Line	:	3025 SILVER LAKE RD NE
Second Line	:
City	:	SAINT ANTHONY
State	:	MN
Zip	:	55418
Country	:	US
Telephone Number	:	651-285-6363
Fax Number	:

Provider Business Practice Location Address
First Line	:	3025 SILVER LAKE RD NE
Second Line	:
City	:	SAINT ANTHONY
State	:	MN
Zip	:	55418-2435
Country	:	US
Telephone Number	:	651-285-6363
Fax Number	:

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

Provider Enumeration Date	:	01/25/2017
Last Update Date	:	10/25/2018

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