MEDICARE: NICOLE MARIE HALIBURTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1932038171
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARIE HALIBURTON

Provider Business Mailing Address
First Line	:	20251 CONLEY ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-2257
Country	:	US
Telephone Number	:	313-474-0636
Fax Number	:

Provider Business Practice Location Address
First Line	:	20251 CONLEY ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-2257
Country	:	US
Telephone Number	:	313-474-0636
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/14/2026
Last Update Date	:	05/14/2026

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Directions to “ NICOLE MARIE HALIBURTON ” Practice Location

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