Provider Demographics
NPI:1174070783
Name:BROWETT-DYKSTRA, NICOLE LYNN (LMSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:BROWETT-DYKSTRA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:BROWETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMSW
Mailing Address - Street 1:790 FULLER AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-1918
Mailing Address - Country:US
Mailing Address - Phone:616-855-5128
Mailing Address - Fax:616-336-8830
Practice Address - Street 1:790 FULLER AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-855-5128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-01
Last Update Date:2025-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010905831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical