Provider Demographics
NPI:1023394749
Name:HESS, NICOLE KATHRYN (BA SST)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:KATHRYN
Last Name:HESS
Suffix:
Gender:F
Credentials:BA SST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 COACHMAN DR
Mailing Address - Street 2:APT. 3A
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-4723
Mailing Address - Country:US
Mailing Address - Phone:248-210-6615
Mailing Address - Fax:
Practice Address - Street 1:14799 DIX TOLEDO RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2507
Practice Address - Country:US
Practice Address - Phone:248-210-6615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-26
Last Update Date:2011-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803086317104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker