Provider Demographics
NPI:1124511878
Name:MIELNICKI, NICOLE ADELA (LCSWA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ADELA
Last Name:MIELNICKI
Suffix:
Gender:F
Credentials:LCSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4602 WATERFORD KNOLL DR APT 1527
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-8650
Mailing Address - Country:US
Mailing Address - Phone:631-255-3819
Mailing Address - Fax:
Practice Address - Street 1:5200 PARK RD STE 102C
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-3650
Practice Address - Country:US
Practice Address - Phone:704-433-5267
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP012382104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker