Basic Information
| Provider Information | |||||||||
| NPI: | 1780776989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIETZ | ||||||||
| FirstName: | LAUREN | ||||||||
| MiddleName: | WILSON | ||||||||
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| Credential: | LICSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2122 KNAPP ST | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551081813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711454 | ||||||||
| FaxNumber: | 6128711505 | ||||||||
| Practice Location | |||||||||
| Address1: | 2430 NICOLLET AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554043461 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128711454 | ||||||||
| FaxNumber: | 6128711505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 1041C0700X | 16009 | MN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.