Basic Information
| Provider Information | |||||||||
| NPI: | 1659650638 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITELAW | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | DOUGLAS CAMPBELL | ||||||||
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| Credential: | LMSW, LMFT, ACSW, NA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2045 E WEST MAPLE RD | ||||||||
| Address2: | SUITE D-407 | ||||||||
| City: | COMMERCE TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483903801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486243811 | ||||||||
| FaxNumber: | 2486240368 | ||||||||
| Practice Location | |||||||||
| Address1: | 114 ORCHARD LAKE RD | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483412244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488587766 | ||||||||
| FaxNumber: | 2488587201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2011 | ||||||||
| LastUpdateDate: | 08/09/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801017103 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | 4101005142 | MI | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1883825 | 05 | MI | MEDICAID |