Provider Demographics
NPI:1205446275
Name:MCGILL, NICOLE MARIE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:MCGILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1749 COUNTY ROAD CKK
Mailing Address - Street 2:
Mailing Address - City:CHAMPION
Mailing Address - State:MI
Mailing Address - Zip Code:49814-9617
Mailing Address - Country:US
Mailing Address - Phone:906-362-4999
Mailing Address - Fax:
Practice Address - Street 1:1749 COUNTY ROAD CKK
Practice Address - Street 2:
Practice Address - City:CHAMPION
Practice Address - State:MI
Practice Address - Zip Code:49814-9617
Practice Address - Country:US
Practice Address - Phone:906-362-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011076451041C0700X
MI68011005411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical