Provider Demographics
NPI:1073764015
Name:WALBY, NICOLE (MALLPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WALBY
Suffix:
Gender:F
Credentials:MALLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12850 FOUNTAIN SQ
Mailing Address - Street 2:SUITE 106
Mailing Address - City:DAVISBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48350-2552
Mailing Address - Country:US
Mailing Address - Phone:586-412-5321
Mailing Address - Fax:
Practice Address - Street 1:42669 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-5036
Practice Address - Country:US
Practice Address - Phone:586-412-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-08
Last Update Date:2008-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011068101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional