Healthcare Provider Details

I. General information

NPI: 1194632406
Provider Name (Legal Business Name): DAKOTA JAMES NICELY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8080 ELIZABETH LAKE RD
WHITE LAKE MI
48386-3410
US

IV. Provider business mailing address

501 N CASS LAKE RD
WATERFORD MI
48328-2307
US

V. Phone/Fax

Practice location:
  • Phone: 248-698-9230
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6851118853
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: