1780787135 NPI number — MRS. PHYLLIS T EDELSTEIN MSW LMSW

Table of content: MRS. PHYLLIS T EDELSTEIN MSW LMSW (NPI 1780787135)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780787135 NPI number — MRS. PHYLLIS T EDELSTEIN MSW LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EDELSTEIN
Provider First Name:
PHYLLIS
Provider Middle Name:
T
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MSW 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:
1780787135
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4187 ANTIQUE LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD HILLS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48302
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-626-7539
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 NORTH CENTER ST SUITE 202
Provider Second Line Business Practice Location Address:
NORTHVILLE COUNSELING CENTER MEGIRA
Provider Business Practice Location Address City Name:
NORTHVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48167
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-347-3470
Provider Business Practice Location Address Fax Number:
248-347-2242
Provider Enumeration Date:
09/07/2006

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:  6801072134 , 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)





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