Basic Information
| Provider Information | |||||||||
| NPI: | 1043791676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRASS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | KAY | ||||||||
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| Credential: | LADC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1900 SILVER LAKE RD NW STE 110 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
| FaxNumber: | 6526280411 | ||||||||
| Practice Location | |||||||||
| Address1: | 11010 PRAIRIE LAKES DR STE 350 | ||||||||
| Address2: | |||||||||
| City: | EDEN PRAIRIE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553443801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9527462522 | ||||||||
| FaxNumber: | 9527460887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2018 | ||||||||
| LastUpdateDate: | 09/20/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 302912 | MN | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.