Provider Demographics
NPI:1093379414
Name:NIKLOWICZ, PHILLIP EDWARD (TLLP)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:EDWARD
Last Name:NIKLOWICZ
Suffix:
Gender:M
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2014 KOLLEN ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-2731
Mailing Address - Country:US
Mailing Address - Phone:734-837-6079
Mailing Address - Fax:
Practice Address - Street 1:300 N ELBA RD
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-8077
Practice Address - Country:US
Practice Address - Phone:810-969-4442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-01
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301017751103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301017751OtherTEMPORARY LIMITED LICENSED PSYCHOLOGIST