Healthcare Provider Details

I. General information

NPI: 1689597593
Provider Name (Legal Business Name): NICOLE L CARLISLE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15600 19 MILE RD
CLINTON TOWNSHIP MI
48038-3502
US

IV. Provider business mailing address

15600 19 MILE RD
CLINTON TOWNSHIP MI
48038-3502
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-8700
  • Fax:
Mailing address:
  • Phone: 586-596-1469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801114112
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: