Provider Demographics
NPI:1902318165
Name:OLIVAS, NICOLE TAYLOR (PHD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:TAYLOR
Last Name:OLIVAS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MONROE AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1455
Mailing Address - Country:US
Mailing Address - Phone:616-259-7207
Mailing Address - Fax:
Practice Address - Street 1:1000 MONROE AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-1455
Practice Address - Country:US
Practice Address - Phone:616-259-7207
Practice Address - Fax:616-259-7261
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301018955103T00000X
103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist