=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275038119
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NIKKI SOMERS-KLANSECK
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2018
-----------------------------------------------------
Last Update Date | 09/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4800 S SAGINAW ST
-----------------------------------------------------
City | FLINT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48507-2677
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-275-9153
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10094 N HUNT CT
-----------------------------------------------------
City | DAVISON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48423-3525
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-814-0575
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 6362009384
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------