Provider Demographics
NPI:1205976784
Name:NIENHUIS, PHILLIP (LMSW)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:NIENHUIS
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 CHICAGO DR STE 205
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1411
Mailing Address - Country:US
Mailing Address - Phone:616-426-9034
Mailing Address - Fax:
Practice Address - Street 1:3424 CHICAGO DR STE 205
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1411
Practice Address - Country:US
Practice Address - Phone:616-426-9034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010872021041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4483587Medicaid
MID16266007Medicare UPIN