Provider Demographics
NPI:1730570151
Name:BROWN, NICOLE (LPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:BROWN
Other - Last Name:VASHON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LLP
Mailing Address - Street 1:2215 29TH ST SE STE B8A
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-1565
Mailing Address - Country:US
Mailing Address - Phone:616-690-5396
Mailing Address - Fax:
Practice Address - Street 1:3250 36TH ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-8193
Practice Address - Country:US
Practice Address - Phone:616-942-7294
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-06
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401017587101Y00000X
MI6301015845101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICV0154400Medicaid