Provider Demographics
NPI:1205411956
Name:WAUGH, NICOLE RAE (LLMSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:RAE
Last Name:WAUGH
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49548-6927
Mailing Address - Country:US
Mailing Address - Phone:616-455-5000
Mailing Address - Fax:248-281-6459
Practice Address - Street 1:300 68TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49548-6927
Practice Address - Country:US
Practice Address - Phone:616-455-5000
Practice Address - Fax:248-281-6459
Is Sole Proprietor?:No
Enumeration Date:2021-03-15
Last Update Date:2023-06-20
Deactivation Date:2023-05-31
Deactivation Code:
Reactivation Date:2023-06-19
Provider Licenses
StateLicense IDTaxonomies
MI6851116582104100000X
156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No156F00000XEye and Vision Services ProvidersTechnician/Technologist