Provider Demographics
NPI:1962750257
Name:NETTLES, MICHAEL W
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:W
Last Name:NETTLES
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:W
Other - Last Name:NETTLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPC/LCPC
Mailing Address - Street 1:5206 MINEOLA RD
Mailing Address - Street 2:
Mailing Address - City:COLLEGE PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20740-4612
Mailing Address - Country:US
Mailing Address - Phone:202-247-1999
Mailing Address - Fax:301-513-0181
Practice Address - Street 1:1858 ROCHELLE AVE
Practice Address - Street 2:
Practice Address - City:CAPITOL HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:20743-4306
Practice Address - Country:US
Practice Address - Phone:202-247-1999
Practice Address - Fax:301-513-0181
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-17
Last Update Date:2012-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC4560101YP2500X
DCPRC14104101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional