Healthcare Provider Details

I. General information

NPI: 1174070783
Provider Name (Legal Business Name): NICOLE LYNN BROWETT-DYKSTRA LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE BROWETT LMSW

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 FULLER AVE NE
GRAND RAPIDS MI
49503
US

IV. Provider business mailing address

790 FULLER AVE NE
GRAND RAPIDS MI
49503-1918
US

V. Phone/Fax

Practice location:
  • Phone: 616-855-5128
  • Fax:
Mailing address:
  • Phone: 616-855-5128
  • Fax: 616-336-8830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801090583
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: