Healthcare Provider Details

I. General information

NPI: 1700252012
Provider Name (Legal Business Name): NICOLE WOZNIAK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2015
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 PLYMOUTH RD STE 250
PLYMOUTH MI
48170
US

IV. Provider business mailing address

42736 SWAN LAKE DR APT 204
NORTHVILLE MI
48167-3114
US

V. Phone/Fax

Practice location:
  • Phone: 734-416-9098
  • Fax:
Mailing address:
  • Phone: 586-453-4539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSYPAT00218240
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: