Basic Information
| Provider Information | |||||||||
| NPI: | 1710414909 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FRAUSTO | ||||||||
| FirstName: | SONIA | ||||||||
| MiddleName: | LETICIA | ||||||||
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| Credential: | SW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3353 LOUSMA DR SE | ||||||||
| Address2: | |||||||||
| City: | WYOMING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495482251 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 BALL AVE NE | ||||||||
| Address2: | |||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495055904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6164566571 | ||||||||
| FaxNumber: | 6164585430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2017 | ||||||||
| LastUpdateDate: | 11/13/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6802088811 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.