Healthcare Provider Details

I. General information

NPI: 1104502673
Provider Name (Legal Business Name): EMILY MORGAN NIKODEMSKI LLPC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 05/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3333 EVERGREEN DR NE STE 210
GRAND RAPIDS MI
49525-9830
US

IV. Provider business mailing address

2145 RICHVIEW AVE NW
GRAND RAPIDS MI
49534-1252
US

V. Phone/Fax

Practice location:
  • Phone: 616-600-2845
  • Fax:
Mailing address:
  • Phone: 616-304-1562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451023044
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: