Basic Information
| Provider Information | |||||||||
| NPI: | 1356962658 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NICOLE M NOVAK LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5005 PLAINFIELD AVE NE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162793869 | ||||||||
| FaxNumber: | 6166084657 | ||||||||
| Practice Location | |||||||||
| Address1: | 5005 PLAINFIELD AVE NE STE 100 | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162793869 | ||||||||
| FaxNumber: | 6166084657 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2020 | ||||||||
| LastUpdateDate: | 04/28/2020 | ||||||||
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| AuthorizedOfficialLastName: | KOTCHKA | ||||||||
| AuthorizedOfficialFirstName: | NICOLE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PROVIDER | ||||||||
| AuthorizedOfficialTelephone: | 6162793869 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMSW,CAADC | ||||||||
| NPICertificationDate: | 04/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.