1093983173 NPI number — MRS. KRYSANDRA LYNN PHELAN LMSW

Table of content: MRS. KRYSANDRA LYNN PHELAN LMSW (NPI 1093983173)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093983173 NPI number — MRS. KRYSANDRA LYNN PHELAN LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHELAN
Provider First Name:
KRYSANDRA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
GREWE
Provider Other First Name:
KRYSANDRA
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093983173
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9844 DIXIE HWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRA
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48023-2813
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
810-434-6371
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9844 DIXIE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48023-2813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-434-6371
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 104100000X , with the licence number:  6801089204 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1093983173 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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