MEDICARE: NICOLE DIANE SHIFFLETT LCSW

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	5169	HI
2	1041C0700X	Clinical Social Worker	CSW.09930877	CO
3	104100000X	Social Worker	2994	HI

General Provider Information

NPI Number	:	1710638416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE DIANE SHIFFLETT LCSW

Provider Business Mailing Address
First Line	:	10684 CALISTA WAY
Second Line	:
City	:	FOUNTAIN
State	:	CO
Zip	:	80817-7266
Country	:	US
Telephone Number	:	405-812-9159
Fax Number	:	808-481-4850

Provider Business Practice Location Address
First Line	:	10684 CALISTA WAY
Second Line	:
City	:	FOUNTAIN
State	:	CO
Zip	:	80817-7266
Country	:	US
Telephone Number	:	405-812-9159
Fax Number	:	808-481-4850

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

Provider Enumeration Date	:	01/13/2022
Last Update Date	:	04/15/2026

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