Basic Information
| Provider Information | |||||||||
| NPI: | 1831571710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VAZ | ||||||||
| FirstName: | NADINE | ||||||||
| MiddleName: | VALERIE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JOHNSON | ||||||||
| OtherFirstName: | NADINE | ||||||||
| OtherMiddleName: | VALERIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2820 BAKER RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | DEXTER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481301196 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345802920 | ||||||||
| FaxNumber: | 7345802922 | ||||||||
| Practice Location | |||||||||
| Address1: | 3493 WOODS EDGE | ||||||||
| Address2: | STE 103 | ||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488645911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5178863707 | ||||||||
| FaxNumber: | 5173491973 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2015 | ||||||||
| LastUpdateDate: | 09/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801081893 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.