Provider Demographics
NPI:1356649354
Name:BARNES, NICOLE RAE (LICSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:BARNES
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3148 FLAG AVE N
Mailing Address - Street 2:
Mailing Address - City:NEW HOPE
Mailing Address - State:MN
Mailing Address - Zip Code:55427-2430
Mailing Address - Country:US
Mailing Address - Phone:763-593-1872
Mailing Address - Fax:
Practice Address - Street 1:6500 EXCELSIOR BLVD
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426-4702
Practice Address - Country:US
Practice Address - Phone:952-993-6299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-01
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN122451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical