Provider Demographics
NPI:1982940839
Name:MINTY, NICOLE M (LMSW)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:M
Last Name:MINTY
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 1:89 W SOUTH BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-1612
Mailing Address - Country:US
Mailing Address - Phone:800-693-1916
Mailing Address - Fax:248-605-3525
Practice Address - Street 1:89 W SOUTH BLVD STE 200
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-1612
Practice Address - Country:US
Practice Address - Phone:800-693-1916
Practice Address - Fax:248-605-3525
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801094535104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker