Provider Demographics
NPI:1376900605
Name:NICOLET, MALEA (LLPC)
Entity type:Individual
Prefix:
First Name:MALEA
Middle Name:
Last Name:NICOLET
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2164 PARSLOW DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-2784
Mailing Address - Country:US
Mailing Address - Phone:616-638-6168
Mailing Address - Fax:
Practice Address - Street 1:1345 MONROE AVE NW STE 332
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-4673
Practice Address - Country:US
Practice Address - Phone:616-638-6168
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-17
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451023731101YP2500X
101YM0800X, 101YP2500X
MI7501006782225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist