Provider Demographics
NPI:1720464092
Name:YOST, NICOLE (MA, LLC)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:YOST
Suffix:
Gender:F
Credentials:MA, LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 MOORE ST
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1110
Mailing Address - Country:US
Mailing Address - Phone:810-834-9130
Mailing Address - Fax:
Practice Address - Street 1:624 W NEPESSING ST STE 300
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-2089
Practice Address - Country:US
Practice Address - Phone:810-667-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451015601101YM0800X
247200000X
MI6401015601101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1720464092Medicaid