Healthcare Provider Details

I. General information

NPI: 1831223197
Provider Name (Legal Business Name): NICOLE RUNYON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 11/21/2022
Certification Date: 11/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 KERCHEVAL AVE STE 14
GROSSE POINTE FARMS MI
48236-3656
US

IV. Provider business mailing address

63 KERCHEVAL AVE STE 14
GROSSE POINTE FARMS MI
48236-3656
US

V. Phone/Fax

Practice location:
  • Phone: 313-215-1186
  • Fax:
Mailing address:
  • Phone: 313-215-1186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801085894
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: