Healthcare Provider Details

I. General information

NPI: 1134048010
Provider Name (Legal Business Name): NICHOLAS DECOUTO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2026
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6995 W 48TH ST
FREMONT MI
49412-9506
US

IV. Provider business mailing address

2701 CRYSTAL LAKE RD LOT 8
WHITEHALL MI
49461-9510
US

V. Phone/Fax

Practice location:
  • Phone: 231-335-1718
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number6451025243
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: