Provider Demographics
NPI:1366176661
Name:FETTIG, NICOLE MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:FETTIG
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1237 W DIVIDE AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-1208
Mailing Address - Country:US
Mailing Address - Phone:701-319-7121
Mailing Address - Fax:
Practice Address - Street 1:1237 W DIVIDE AVE STE 5
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-1208
Practice Address - Country:US
Practice Address - Phone:701-319-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-12
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND61291041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical