Basic Information
| Provider Information | |||||||||
| NPI: | 1164091567 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVRIES | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2298 BYRON SHORES DR SW | ||||||||
| Address2: | |||||||||
| City: | BYRON CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493158378 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6163662963 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 325 84TH ST SW STE 102 | ||||||||
| Address2: | |||||||||
| City: | BYRON CENTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493159350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168053660 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2021 | ||||||||
| LastUpdateDate: | 06/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801093561 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.