Basic Information
| Provider Information | |||||||||
| NPI: | 1740505460 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LIEDTKE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW, LCAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALLACE | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW, LCAC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3645 N BRIARWOOD LN | ||||||||
| Address2: | STE A | ||||||||
| City: | MUNCIE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473045337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7652895520 | ||||||||
| FaxNumber: | 7652895840 | ||||||||
| Practice Location | |||||||||
| Address1: | 14074 TRADE CENTER DR | ||||||||
| Address2: | STE 220 | ||||||||
| City: | FISHERS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460384575 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3177757797 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2010 | ||||||||
| LastUpdateDate: | 12/10/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 87001005A | IN | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 34005950A | IN | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 000001111107 | 01 | IN | ANTHEM BLUE CROSS BLUE SHIELD | OTHER | 34005950A | 01 | IN | LCSW | OTHER |