Nicole Marie Liedtke, LCSW, LCAC

Primary specialty

Clinical Social WorkerTaxonomy code 1041C0700X

License

34005950A Issued in IN

Practice address

14074 Trade Center Dr
Ste 220
Fishers, IN 46038-4575

Phone

(317) 775-7797

NPI assigned

Apr 6, 2010

Last updated

Dec 10, 2020By the provider in NPPES

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Other names 1

• Nicole Marie Wallace Former name

Medicare fee-for-service enrollment

Enrolled in IN

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: No
• Power mobility devices: No
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Clinical Social Worker

Education

Other, 2006

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• Restore and Recover Counseling LLC

  • Clinical Social Worker
  • Fishers, IN
  • NPI 1417553793
  Medicare reassignment NPD Authorized official
• Tyrow Consulting LLC

  dba The Briarwood Clinic

  • Mental Health Clinic/Center (Including Community Mental Health Center)
  • Muncie, IN
  • NPI 1710384839
  Medicare reassignment NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1270512000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1607558400000",
    "number": "1740505460",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3645 N BRIARWOOD LN",
            "address_2": "STE A",
            "city": "MUNCIE",
            "state": "IN",
            "postal_code": "473045337",
            "telephone_number": "765-289-5520",
            "fax_number": "765-289-5840"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "14074 TRADE CENTER DR",
            "address_2": "STE 220",
            "city": "FISHERS",
            "state": "IN",
            "postal_code": "460384575",
            "telephone_number": "317-775-7797"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "LIEDTKE",
        "first_name": "NICOLE",
        "middle_name": "MARIE",
        "credential": "LCSW, LCAC",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2010-04-06",
        "last_updated": "2020-12-10",
        "certification_date": "2020-12-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": "IN",
            "license": "87001005A",
            "primary": false
        },
        {
            "code": "1041C0700X",
            "taxonomy_group": "",
            "desc": "Social Worker, Clinical",
            "state": "IN",
            "license": "34005950A",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "LCSW",
            "identifier": "34005950A",
            "state": "IN"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "ANTHEM BLUE CROSS BLUE SHIELD",
            "identifier": "000001111107",
            "state": "IN"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "first_name": "NICOLE",
            "last_name": "WALLACE",
            "middle_name": "MARIE",
            "credential": "LCSW, LCAC",
            "code": "1",
            "type": "Former Name"
        }
    ]
}

• Anne P Lewis, PHD, HSPP. LCAC
• Denisha Lewis
• Samantha Lewis
• Kathryn I Li, RPH
• Christine M Liedtke, PSY.D., HSPP
• Life Refined Chiropractic, LLC (Life Refined Chiropractic)
• Lifestyle Mobility Plus, Inc. (Lifestyle Mobility Plus)
• Lifetime Dental Care of Indiana, PC (Brookschool Dental Care)
• Rita S Liming, NP
• Robert J Lindeman, MD

• Clinical Social Worker in Fishers, IN
• Providers in Fishers, IN by specialty
• Clinical Social Worker in Indiana

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 10, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.