Provider Demographics
NPI:1447278353
Name:AMUNDSEN, NICOLE (LCSW, MSW)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:AMUNDSEN
Suffix:
Gender:F
Credentials:LCSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1609 MEADOW LN
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-5261
Mailing Address - Country:US
Mailing Address - Phone:919-593-4501
Mailing Address - Fax:
Practice Address - Street 1:1829 E FRANKLIN ST
Practice Address - Street 2:SUITE 900-B
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-5861
Practice Address - Country:US
Practice Address - Phone:919-593-4501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0045991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003192Medicaid