Provider Demographics
NPI:1548523897
Name:MUNGER, NICOLE (LICSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MUNGER
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 1:2230 COMO AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55108-1720
Mailing Address - Country:US
Mailing Address - Phone:651-645-5323
Mailing Address - Fax:651-641-6190
Practice Address - Street 1:2230 COMO AVE
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55108-1720
Practice Address - Country:US
Practice Address - Phone:651-645-5323
Practice Address - Fax:651-641-6190
Is Sole Proprietor?:No
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN199081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical