Provider Demographics
NPI:1619607827
Name:GENDRON, NICHOLAUS B
Entity Type:Individual
Prefix:
First Name:NICHOLAUS
Middle Name:B
Last Name:GENDRON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2521 N ELMS RD
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:MI
Mailing Address - Zip Code:48433-9423
Mailing Address - Country:US
Mailing Address - Phone:866-498-3909
Mailing Address - Fax:
Practice Address - Street 1:11174 HIGHLAND RD
Practice Address - Street 2:
Practice Address - City:HARTLAND
Practice Address - State:MI
Practice Address - Zip Code:48353-2702
Practice Address - Country:US
Practice Address - Phone:810-991-1114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician