MEDICARE: NIKKI RAE WIEBERDINK

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	101YP2500X	Professional Counselor	CC01194	MN

General Provider Information

NPI Number	:	1558886382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIKKI RAE WIEBERDINK

Provider Business Mailing Address
First Line	:	3400 1ST ST N STE 101
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56303-1924
Country	:	US
Telephone Number	:	320-202-2024
Fax Number	:

Provider Business Practice Location Address
First Line	:	3333 W DIVISION ST STE 209
Second Line	:
City	:	SAINT CLOUD
State	:	MN
Zip	:	56301-4322
Country	:	US
Telephone Number	:	320-253-5555
Fax Number	:	320-529-1976

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

Provider Enumeration Date	:	08/14/2017
Last Update Date	:	06/16/2018

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Directions to “ NIKKI RAE WIEBERDINK ” Practice Location

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