Healthcare Provider Details

I. General information

NPI: 1417648908
Provider Name (Legal Business Name): HEATHER NITZKI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2023
Last Update Date: 05/16/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 CASCADE RD SE STE D
GRAND RAPIDS MI
49546-3808
US

IV. Provider business mailing address

5060 CASCADE RD SE STE D
GRAND RAPIDS MI
49546-3808
US

V. Phone/Fax

Practice location:
  • Phone: 331-625-3796
  • Fax:
Mailing address:
  • Phone: 331-625-3796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: HEATHER NITZKI
Title or Position: PROVIDER
Credential:
Phone: 331-625-3796