1992938237 NPI number — MRS. NICOLE L DUFOUR L.I.C.S.W.

Table of content: MRS. NICOLE L DUFOUR L.I.C.S.W. (NPI 1992938237)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992938237 NPI number — MRS. NICOLE L DUFOUR L.I.C.S.W.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUFOUR
Provider First Name:
NICOLE
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
L.I.C.S.W.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992938237
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1875 STATION PKWY NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANDOVER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55304-3319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-482-9598
Provider Business Mailing Address Fax Number:
612-235-6447

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1875 STATION PKWY NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANDOVER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-482-9598
Provider Business Practice Location Address Fax Number:
612-235-6447
Provider Enumeration Date:
09/03/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  17089 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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