Basic Information
| Provider Information | |||||||||
| NPI: | 1598102873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ERCHUL | ||||||||
| FirstName: | NICOLETTE | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 621 W LAKE ST | ||||||||
| Address2: | STE 350 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554082952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6129792276 | ||||||||
| FaxNumber: | 6519250427 | ||||||||
| Practice Location | |||||||||
| Address1: | 1360 ENERGY PARK DR STE 340 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551085298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516468985 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2013 | ||||||||
| LastUpdateDate: | 01/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 20517 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | H400139162 | 01 | MN | MEDICARE PTAN | OTHER | 006958400 | 05 | MN | MEDICAID |