Provider Demographics
NPI:1992056584
Name:NERSESIAN, MARIAM MADELINE (LPC)
Entity type:Individual
Prefix:MRS
First Name:MARIAM
Middle Name:MADELINE
Last Name:NERSESIAN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:MARIAM
Other - Middle Name:MADELINE
Other - Last Name:ONESIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:602 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-1907
Mailing Address - Country:US
Mailing Address - Phone:517-783-5334
Mailing Address - Fax:517-836-6064
Practice Address - Street 1:602 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-1907
Practice Address - Country:US
Practice Address - Phone:517-783-5334
Practice Address - Fax:517-836-6064
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013022101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-2833398OtherEIN