Provider Demographics
NPI:1063069615
Name:DESANA, NICOLE MARIE
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:MARIE
Last Name:DESANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25584 MERIDIAN RD
Mailing Address - Street 2:
Mailing Address - City:GROSSE ILE
Mailing Address - State:MI
Mailing Address - Zip Code:48138-1694
Mailing Address - Country:US
Mailing Address - Phone:734-778-0380
Mailing Address - Fax:
Practice Address - Street 1:17200 W OUTER DR STE A
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127-2457
Practice Address - Country:US
Practice Address - Phone:313-278-4610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician