Provider Demographics
NPI:1114151941
Name:DWYER, NICOLE MARIE (LLPC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:DWYER
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:REDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15219 CORNELL DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-1094
Mailing Address - Country:US
Mailing Address - Phone:586-604-3845
Mailing Address - Fax:
Practice Address - Street 1:43900 GARFIELD RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48038-1128
Practice Address - Country:US
Practice Address - Phone:586-263-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011257101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health