Provider Demographics
NPI:1104287721
Name:KIRK, NICHOLAS DOMINIC
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:DOMINIC
Last Name:KIRK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4850 136TH AVE
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MI
Mailing Address - Zip Code:49419-9604
Mailing Address - Country:US
Mailing Address - Phone:630-890-4315
Mailing Address - Fax:
Practice Address - Street 1:4850 136TH AVE
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:MI
Practice Address - Zip Code:49419-9604
Practice Address - Country:US
Practice Address - Phone:630-890-4315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-09
Last Update Date:2023-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT122998106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist