Provider Demographics
NPI:1124491113
Name:WAIT, NIKKI
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:WAIT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 17TH AVE NW
Mailing Address - Street 2:STE 2
Mailing Address - City:GLENWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56334-2159
Mailing Address - Country:US
Mailing Address - Phone:320-634-3446
Mailing Address - Fax:320-634-0384
Practice Address - Street 1:100 17TH AVE NW
Practice Address - Street 2:STE 2
Practice Address - City:GLENWOOD
Practice Address - State:MN
Practice Address - Zip Code:56334-2159
Practice Address - Country:US
Practice Address - Phone:320-634-3446
Practice Address - Fax:320-634-0384
Is Sole Proprietor?:No
Enumeration Date:2015-11-12
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN304087101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)