Basic Information
| Provider Information | |||||||||
| NPI: | 1154803484 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAURA | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | LLMSW, CAADC-DP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14796 SHENANDOAH DR BLDG 24 | ||||||||
| Address2: | |||||||||
| City: | RIVERVIEW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481937731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349252016 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6309 MACK AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482072302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133965300 | ||||||||
| FaxNumber: | 3133965353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2018 | ||||||||
| LastUpdateDate: | 09/23/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801110369 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.