1649418708 NPI number — NICOLE L BOURLAKAS-MAURER LMSW, CBIS

Table of content: NICOLE L BOURLAKAS-MAURER LMSW, CBIS (NPI 1649418708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649418708 NPI number — NICOLE L BOURLAKAS-MAURER LMSW, CBIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOURLAKAS-MAURER
Provider First Name:
NICOLE
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW, CBIS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649418708
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1164 JAMES SAVAGE RD
Provider Second Line Business Mailing Address:
SUITE E
Provider Business Mailing Address City Name:
MIDLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48640-6843
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-513-5107
Provider Business Mailing Address Fax Number:
855-483-9638

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1164 JAMES SAVAGE RD
Provider Second Line Business Practice Location Address:
SUITE E
Provider Business Practice Location Address City Name:
MIDLAND
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48640-6843
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-513-5107
Provider Business Practice Location Address Fax Number:
855-483-9638
Provider Enumeration Date:
01/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801085334 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 730195 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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