Provider Demographics
NPI:1053814392
Name:BETHEA, NIKOLE (LLP)
Entity Type:Individual
Prefix:
First Name:NIKOLE
Middle Name:
Last Name:BETHEA
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:NIKOLE
Other - Middle Name:
Other - Last Name:BAYLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LLP
Mailing Address - Street 1:753 W SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:MI
Mailing Address - Zip Code:48813-1319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:123 S COCHRAN AVE STE D
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1509
Practice Address - Country:US
Practice Address - Phone:517-231-2110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2023-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6361007599103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist