Provider Demographics
NPI:1154094605
Name:MELVILLE, NICHOLAS J (LLPC)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:J
Last Name:MELVILLE
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6568 W MILL RUN SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-7861
Mailing Address - Country:US
Mailing Address - Phone:616-633-0269
Mailing Address - Fax:
Practice Address - Street 1:1360 BALDWIN ST
Practice Address - Street 2:
Practice Address - City:JENISON
Practice Address - State:MI
Practice Address - Zip Code:49428-8937
Practice Address - Country:US
Practice Address - Phone:616-202-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451019552101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional