Healthcare Provider Details

I. General information

NPI: 1417605833
Provider Name (Legal Business Name): NICOLE WILDEMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2022
Last Update Date: 04/09/2026
Certification Date: 04/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14229 TORREY RD # 3
FENTON MI
48430-3308
US

IV. Provider business mailing address

2421 GOLDEN SHORE DR
FENTON MI
48430-1058
US

V. Phone/Fax

Practice location:
  • Phone: 810-214-2624
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberTPMC5026
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401222623
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: