Provider Demographics
NPI:1437683620
Name:MACON-MCKENDREE, NICOLE (LMSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MACON-MCKENDREE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:RANSOM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:42217 ANN ARBOR RD E
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-4364
Mailing Address - Country:US
Mailing Address - Phone:480-492-8672
Mailing Address - Fax:
Practice Address - Street 1:42217 ANN ARBOR RD E
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-4364
Practice Address - Country:US
Practice Address - Phone:480-492-8672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-14
Last Update Date:2023-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-166301041C0700X
MI68011105431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical