Provider Demographics
NPI:1790203750
Name:NICOLICH, KRIS SANDRA (LLP)
Entity Type:Individual
Prefix:MRS
First Name:KRIS
Middle Name:SANDRA
Last Name:NICOLICH
Suffix:
Gender:F
Credentials:LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3265 EASTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MI
Mailing Address - Zip Code:48130-9392
Mailing Address - Country:US
Mailing Address - Phone:734-718-4579
Mailing Address - Fax:
Practice Address - Street 1:3258 BROAD ST
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MI
Practice Address - Zip Code:48130-1142
Practice Address - Country:US
Practice Address - Phone:734-718-4579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011113103TB0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral