Basic Information
| Provider Information | |||||||||
| NPI: | 1760795074 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELSON | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 605 W BRAND ST | ||||||||
| Address2: | |||||||||
| City: | DURAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484291120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104964955 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2700 ROBERT T LONGWAY BLVD | ||||||||
| Address2: | SUITE C | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104964955 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2010 | ||||||||
| LastUpdateDate: | 06/30/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.