Provider Demographics
NPI:1194413351
Name:GEORGE, NICOLE L
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:GEORGE
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 1:826 1ST AVE N
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-3997
Mailing Address - Country:US
Mailing Address - Phone:515-573-3931
Mailing Address - Fax:515-573-3950
Practice Address - Street 1:826 1ST AVE N
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-3997
Practice Address - Country:US
Practice Address - Phone:515-573-3931
Practice Address - Fax:515-573-3950
Is Sole Proprietor?:No
Enumeration Date:2023-04-26
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18023101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)