Basic Information
| Provider Information | |||||||||
| NPI: | 1902211998 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEARNOW-BAURHENN | ||||||||
| FirstName: | ALLYSA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LMSW, CADC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FEARNOW | ||||||||
| OtherFirstName: | ALLYSA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LLMSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6800 E 10 MILE RD | ||||||||
| Address2: | |||||||||
| City: | CENTER LINE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480151167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5866199986 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 18 MARKET ST STE C | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480437403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867832222 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2014 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 08/13/2021 | ||||||||
| NPIReactivationDate: | 09/23/2021 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 1041C0700X | 6801109347 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.