Provider Demographics
NPI:1518437433
Name:POMINVILLE, NICOLE (LLPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:POMINVILLE
Suffix:
Gender:F
Credentials:LLPC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:DERYDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1608 LAKE ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-3170
Mailing Address - Country:US
Mailing Address - Phone:269-344-0202
Mailing Address - Fax:269-344-0285
Practice Address - Street 1:1608 LAKE ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-3170
Practice Address - Country:US
Practice Address - Phone:269-344-0202
Practice Address - Fax:269-344-0285
Is Sole Proprietor?:No
Enumeration Date:2018-12-04
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016281101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional