Healthcare Provider Details

I. General information

NPI: 1669366597
Provider Name (Legal Business Name): COURTNEY LACE ANNE NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2025
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 N SHIAWASSEE ST STE A
CORUNNA MI
48817-1444
US

IV. Provider business mailing address

158 MEADOWWOOD LN APT 70
CHESANING MI
48616-1176
US

V. Phone/Fax

Practice location:
  • Phone: 989-928-3566
  • Fax:
Mailing address:
  • Phone: 810-287-1204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: