Provider Demographics
NPI:1992416002
Name:WILLIAMS, NICOLE ANNE (LADC, LPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:LADC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 COUNTY ROAD B W STE 102
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113-4053
Mailing Address - Country:US
Mailing Address - Phone:651-398-6643
Mailing Address - Fax:
Practice Address - Street 1:1611 COUNTY ROAD B W STE 102
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113-4053
Practice Address - Country:US
Practice Address - Phone:651-398-6643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-09
Last Update Date:2024-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN306392101YA0400X
MN2701101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)