1669770137 NPI number — MS. ELIZABETH DIANE STAMP LMSW

Table of content: MS. ELIZABETH DIANE STAMP LMSW (NPI 1669770137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669770137 NPI number — MS. ELIZABETH DIANE STAMP LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STAMP
Provider First Name:
ELIZABETH
Provider Middle Name:
DIANE
Provider Name Prefix Text:
MS.
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669770137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/03/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2215 FULLER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ANN ARBOR
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48105-9922
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-649-8491
Provider Business Mailing Address Fax Number:
734-845-3462

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15082 LAKEVIEW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FENTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48430-1328
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-845-5500
Provider Business Practice Location Address Fax Number:
734-845-3462
Provider Enumeration Date:
03/08/2011

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: 1041C0700X , with the licence number:  6801091086 , 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: VA0506. . This is a "MEDICARE IDENTIFICATION NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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