Provider Demographics
NPI:1730261934
Name:MENDENHALL, NICKY (LISW, LMFT)
Entity type:Individual
Prefix:MS
First Name:NICKY
Middle Name:
Last Name:MENDENHALL
Suffix:
Gender:F
Credentials:LISW, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:939 OFFICE PARK RD
Mailing Address - Street 2:SUITE 112
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-2505
Mailing Address - Country:US
Mailing Address - Phone:515-274-6335
Mailing Address - Fax:515-274-9269
Practice Address - Street 1:939 OFFICE PARK RD
Practice Address - Street 2:SUITE 112
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-2505
Practice Address - Country:US
Practice Address - Phone:515-274-6335
Practice Address - Fax:515-274-9269
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA000101041C0700X
IA00029106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Not Answered106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist