Provider Demographics
NPI:1902317019
Name:PRUST, NICOLE MARIE (LMSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:PRUST
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:343 W SOUTHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-1066
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:103 W US HIGHWAY 2
Practice Address - Street 2:
Practice Address - City:WAKEFIELD
Practice Address - State:MI
Practice Address - Zip Code:49968-9515
Practice Address - Country:US
Practice Address - Phone:906-229-6120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-16
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801101923104100000X
MI68011105991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker