Healthcare Provider Details

I. General information

NPI: 1679583298
Provider Name (Legal Business Name): LIDIJA M NIKOLOVSKA LMSW CSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 12/05/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8021 BURNING BUSH GROSSE ILE,MI 48138
GROSSE MI
48138
US

IV. Provider business mailing address

19598 KATHRON CR
GROSSE ILE MI
48138
US

V. Phone/Fax

Practice location:
  • Phone: 248-245-1130
  • Fax:
Mailing address:
  • Phone: 248-245-1130
  • Fax: 734-642-3424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801067735
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801067735
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: