Provider Demographics
NPI:1336718477
Name:BURNER, NICHOLAS (LLPC)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:BURNER
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3424 CHICAGO DR STE 205
Mailing Address - Street 2:
Mailing Address - City:HUDSONVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49426-1411
Mailing Address - Country:US
Mailing Address - Phone:616-426-9034
Mailing Address - Fax:
Practice Address - Street 1:3424 CHICAGO DR STE 205
Practice Address - Street 2:
Practice Address - City:HUDSONVILLE
Practice Address - State:MI
Practice Address - Zip Code:49426-1411
Practice Address - Country:US
Practice Address - Phone:616-426-9034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2024-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6451019467101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional