Provider Demographics
NPI:1023509155
Name:WINNINGHAM, NICOLE (LMSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WINNINGHAM
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1885 PORTER RD
Mailing Address - Street 2:
Mailing Address - City:WHITE LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48383-2426
Mailing Address - Country:US
Mailing Address - Phone:248-974-5625
Mailing Address - Fax:
Practice Address - Street 1:2200 GENOA BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-5328
Practice Address - Country:US
Practice Address - Phone:810-494-7180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801089751104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker