Basic Information
| Provider Information | |||||||||
| NPI: | 1750829560 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEAN | ||||||||
| FirstName: | ROSETTA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 44899 CENTRE CT | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480385510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867921654 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 44899 CENTRE CT | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | CLINTON TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480385510 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867921654 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2017 | ||||||||
| LastUpdateDate: | 02/01/2017 | ||||||||
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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 | 104100000X | 6803086906 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | 6803086906 | 05 | MI | MEDICAID |