Provider Demographics
NPI:1649418708
Name:BOURLAKAS-MAURER, NICOLE L (LMSW, CBIS)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:BOURLAKAS-MAURER
Suffix:
Gender:F
Credentials:LMSW, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1164 JAMES SAVAGE RD
Mailing Address - Street 2:SUITE E
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-6843
Mailing Address - Country:US
Mailing Address - Phone:989-513-5107
Mailing Address - Fax:855-483-9638
Practice Address - Street 1:1164 JAMES SAVAGE RD
Practice Address - Street 2:SUITE E
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-6843
Practice Address - Country:US
Practice Address - Phone:989-513-5107
Practice Address - Fax:855-483-9638
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010853341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI730195Medicaid
MI0G36205030Medicare PIN