Healthcare Provider Details

I. General information

NPI: 1164091567
Provider Name (Legal Business Name): NICOLE LYNN MICK LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/21/2021
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1403 60TH ST SE
KENTWOOD MI
49508-7065
US

IV. Provider business mailing address

2298 BYRON SHORES DR SW
BYRON CENTER MI
49315-8378
US

V. Phone/Fax

Practice location:
  • Phone: 616-805-3660
  • Fax:
Mailing address:
  • Phone: 616-366-2963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801093561
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: