Provider Demographics
NPI:1528640679
Name:SALZL, NICOLE KAVITA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:KAVITA
Last Name:SALZL
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 1:3101 129TH LN NW
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55448-1102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2705 BUNKER LAKE BLVD NW
Practice Address - Street 2:
Practice Address - City:ANDOVER
Practice Address - State:MN
Practice Address - Zip Code:55304-3784
Practice Address - Country:US
Practice Address - Phone:612-900-0233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-27
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN305449101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)