Provider Demographics
NPI:1457527020
Name:NIELSEN, MICHELE A (MA, LLP, LLPC)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:A
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:MA, LLP, LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 IONIA AVE SW
Mailing Address - Street 2:SUITE 4112
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-4116
Mailing Address - Country:US
Mailing Address - Phone:616-283-3120
Mailing Address - Fax:
Practice Address - Street 1:200 IONIA AVE SW
Practice Address - Street 2:SUITE 4112
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-4116
Practice Address - Country:US
Practice Address - Phone:616-283-3120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013548103TC0700X
MI6401010610103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE