Provider Demographics
NPI:1063501351
Name:MINNIS, NICOLE LYNN (MA, LLP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:LYNN
Last Name:MINNIS
Suffix:
Gender:F
Credentials:MA, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8141 CRESTON DR
Mailing Address - Street 2:
Mailing Address - City:FREELAND
Mailing Address - State:MI
Mailing Address - Zip Code:48623-8722
Mailing Address - Country:US
Mailing Address - Phone:989-245-0371
Mailing Address - Fax:
Practice Address - Street 1:218 FAST ICE DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48642-6167
Practice Address - Country:US
Practice Address - Phone:989-631-2320
Practice Address - Fax:989-631-9214
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011787103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical