Provider Demographics
NPI:1992096267
Name:RUSSEAU, NICHOLAS (MA)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:RUSSEAU
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 E ELM AVE STE 112
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2678
Mailing Address - Country:US
Mailing Address - Phone:734-242-4673
Mailing Address - Fax:734-242-4676
Practice Address - Street 1:214 E ELM AVE STE 112
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-2678
Practice Address - Country:US
Practice Address - Phone:734-242-4673
Practice Address - Fax:734-242-4676
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401012141101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2604097Medicaid
MIOP23520Medicare PIN