Basic Information
| Provider Information | |||||||||
| NPI: | 1447525332 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURMANIA | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ERIN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LLBSW, MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DEVRIES | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | ERIN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 68TH STREET SE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164555000 | ||||||||
| FaxNumber: | 6162816459 | ||||||||
| Practice Location | |||||||||
| Address1: | PINE REST CHRISTIAN MENTAL HEALTH SERVICES | ||||||||
| Address2: | 300 68TH STREET SE | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164555000 | ||||||||
| FaxNumber: | 6162816459 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2012 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 680109276 | MI | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1041C0700X | 685208961 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.