Healthcare Provider Details

I. General information

NPI: 1134791841
Provider Name (Legal Business Name): NICOLE HOLWERDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2021
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 3 MILE RD NW SUITE 200
GRAND RAPIDS MI
49544-1691
US

IV. Provider business mailing address

1345 W EVENTIDE DR NE
GRAND RAPIDS MI
49505-5765
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 616-808-6406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number7401002611
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: