Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 103TC1900X | Counseling Psychologist | 3999 | MN |
N | 1041C0700X | Clinical Social Worker | MN |
NPI | 1073636932 |
---|---|
Provider Name | Connie Nichols Meyer |
First Address | Shoreview, MN 55126-4138 |
Second Address | Shoreview, MN 55126-4138 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 07/04/2007 |
Last Update Date | 08/07/2007 |