Provider Demographics
NPI:1639504673
Name:NYQUIST, LAURIE ELAINE (TLLP)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:ELAINE
Last Name:NYQUIST
Suffix:
Gender:F
Credentials:TLLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4829 E BELTLINE AVE NE
Mailing Address - Street 2:SUITE #103
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9747
Mailing Address - Country:US
Mailing Address - Phone:616-217-8612
Mailing Address - Fax:616-466-7953
Practice Address - Street 1:4829 E BELTLINE AVE NE
Practice Address - Street 2:SUITE #103
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9747
Practice Address - Country:US
Practice Address - Phone:616-217-8612
Practice Address - Fax:616-466-7953
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-10
Last Update Date:2013-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301010905101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional