Provider Demographics
NPI:1992298087
Name:KITTLE, NICOLE MARIE
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:MARIE
Last Name:KITTLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:OUTMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2520 UNIVERSITY PARK
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-4464
Mailing Address - Country:US
Mailing Address - Phone:989-774-2529
Mailing Address - Fax:
Practice Address - Street 1:720 W WACKERLY ST STE 11
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2769
Practice Address - Country:US
Practice Address - Phone:989-832-2165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-13
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
MI6351004491103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty