Provider Demographics
NPI:1497341457
Name:CORDERO, NICOLE MARIE (MS, TLLP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:CORDERO
Suffix:
Gender:F
Credentials:MS, TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45747 LAKEVIEW CT APT 12105
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3846
Mailing Address - Country:US
Mailing Address - Phone:480-678-2842
Mailing Address - Fax:
Practice Address - Street 1:501 N MAPLE RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-2827
Practice Address - Country:US
Practice Address - Phone:734-669-3610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-14
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6362009079103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical