Provider Demographics
NPI:1104434885
Name:NOVAK, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NOVAK
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 PIERPONT DR STE 9
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48911-5976
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5969 N CANTON CENTER RD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187-2757
Practice Address - Country:US
Practice Address - Phone:877-407-3422
Practice Address - Fax:877-407-4329
Is Sole Proprietor?:No
Enumeration Date:2020-07-17
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician