Basic Information
| Provider Information | |||||||||
| NPI: | 1205477262 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARVIDSON | ||||||||
| FirstName: | HANNAH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
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| Credential: | SW-T | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 13101 ALLEN RD BLDG 4 | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
| FaxNumber: | 7347857784 | ||||||||
| Practice Location | |||||||||
| Address1: | 13101 ALLEN RD BLDG 4 | ||||||||
| Address2: | |||||||||
| City: | SOUTHGATE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481952216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347857700 | ||||||||
| FaxNumber: | 7347857784 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/01/2019 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 09/23/2020 | ||||||||
| NPIReactivationDate: | 09/30/2020 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801108042 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | 390200000X | S.190111-TRNE | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.