Provider Demographics
NPI:1386066355
Name:NAKO, NONTLE
Entity type:Individual
Prefix:
First Name:NONTLE
Middle Name:
Last Name:NAKO
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 1:2650 MARFITT RD
Mailing Address - Street 2:APT 16
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-6342
Mailing Address - Country:US
Mailing Address - Phone:517-323-4099
Mailing Address - Fax:517-323-3334
Practice Address - Street 1:5123 W ST JOE HWY
Practice Address - Street 2:STE 103
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-4093
Practice Address - Country:US
Practice Address - Phone:517-323-4099
Practice Address - Fax:517-323-3334
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301013952103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist