Healthcare Provider Details

I. General information

NPI: 1245569052
Provider Name (Legal Business Name): BRYAN JOSEPH NIXON LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2009
Last Update Date: 01/31/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1870 LEONARD ST NE
GRAND RAPIDS MI
49505-5650
US

IV. Provider business mailing address

PO BOX 120125
GRAND RAPIDS MI
49528-0103
US

V. Phone/Fax

Practice location:
  • Phone: 616-956-1122
  • Fax: 616-956-8033
Mailing address:
  • Phone: 616-956-1122
  • Fax: 616-956-8033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401012317
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: