Provider Demographics
NPI:1467540294
Name:BEAGLE, NICOLE M (LBSW, LLP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:M
Last Name:BEAGLE
Suffix:
Gender:F
Credentials:LBSW, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 S FULTON ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:MI
Mailing Address - Zip Code:48471-1345
Mailing Address - Country:US
Mailing Address - Phone:810-648-9249
Mailing Address - Fax:
Practice Address - Street 1:217 E SANILAC RD
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-1383
Practice Address - Country:US
Practice Address - Phone:810-648-4327
Practice Address - Fax:810-648-4338
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802085142104100000X
MI6301013447103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6301013447OtherLIMTD LICENSE MAST PSYCH.
MI6802085142OtherSOCIAL WORK LICENSE