Healthcare Provider Details

I. General information

NPI: 1053859165
Provider Name (Legal Business Name): NICOLE STUDEBAKER CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 02/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35514 INDIGO DR
STERLING HEIGHTS MI
48310-4946
US

IV. Provider business mailing address

35514 INDIGO DR
STERLING HEIGHTS MI
48310-4946
US

V. Phone/Fax

Practice location:
  • Phone: 586-979-8118
  • Fax: 586-979-8118
Mailing address:
  • Phone: 586-979-8118
  • Fax: 586-979-8118

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: