Provider Demographics
NPI:1992108740
Name:MEDIN, NICOLE NEFF (MA)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:NEFF
Last Name:MEDIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:HEISE
Other - Last Name:NEFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT, LADC
Mailing Address - Street 1:541 ATLANTIC HILL DR
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-2049
Mailing Address - Country:US
Mailing Address - Phone:651-329-1960
Mailing Address - Fax:
Practice Address - Street 1:1313 E 66TH ST STE B101
Practice Address - Street 2:
Practice Address - City:RICHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55423-4577
Practice Address - Country:US
Practice Address - Phone:612-758-0773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-07
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN302039101YA0400X
MN2801106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)