Basic Information
| Provider Information | |||||||||
| NPI: | 1063501351 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MINNIS | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MA, LLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8141 CRESTON DR | ||||||||
| Address2: | |||||||||
| City: | FREELAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486238722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892450371 | ||||||||
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| Practice Location | |||||||||
| Address1: | 218 FAST ICE DR | ||||||||
| Address2: | |||||||||
| City: | MIDLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486426167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9896312320 | ||||||||
| FaxNumber: | 9896319214 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 05/15/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 6301011787 | MI | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.