Provider Demographics
NPI:1679206734
Name:NICKESON-MENDHEIM, DIANE
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:
Last Name:NICKESON-MENDHEIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:
Other - Last Name:STREET
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MARRIED NAME
Mailing Address - Street 1:241 CLEVELAND AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-1208
Mailing Address - Country:US
Mailing Address - Phone:651-371-5559
Mailing Address - Fax:
Practice Address - Street 1:241 CLEVELAND AVE S
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-1208
Practice Address - Country:US
Practice Address - Phone:651-371-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL89231041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical