Basic Information
| Provider Information | |||||||||
| NPI: | 1740573104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FARRUG | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MA LPC SCL LSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11800 E 12 MILE RD | ||||||||
| Address2: | EMERGENCY ROOM | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865735872 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11800 E 12 MILE RD | ||||||||
| Address2: | EMERGENCY ROOM | ||||||||
| City: | WARREN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480933472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5865735872 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2011 | ||||||||
| LastUpdateDate: | 05/18/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 6401002292 | MI | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YS0200X | 195786 | MI | N | Behavioral Health & Social Service Providers | Counselor | School | 104100000X | 6802070800 | MI | N | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.