Individual
NICOLE MARIE LIEDTKE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
LCSW, LCAC
Contact information
Practice address
14074 TRADE CENTER DR, STE 220, FISHERS, IN 46038-4575
(317) 775-7797
Mailing address
3645 N BRIARWOOD LN, STE A, MUNCIE, IN 47304-5337
(765) 289-5520
(765) 289-5840
Taxonomy
Speciality
Code
Description
License number
State
101YA0400X
Addiction (Substance Use Disorder) Counselor
87001005A
IN
1041C0700X
Clinical Social Worker
Primary
34005950A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000001111107
ANTHEM BLUE CROSS BLUE SHIELD
IN
01
—
34005950A
LCSW
IN
Enumeration date
04/06/2010
Last updated
12/10/2020
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