Basic Information
| Provider Information | |||||||||
| NPI: | 1912133190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WARKENTIN | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5447 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482024009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138321100 | ||||||||
| FaxNumber: | 3135784507 | ||||||||
| Practice Location | |||||||||
| Address1: | 5447 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482024009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138321100 | ||||||||
| FaxNumber: | 3135784507 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/02/2009 | ||||||||
| LastUpdateDate: | 11/07/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 5201005327 | MI | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 5201005327 | 01 | MI | STATE OF MICHIGAN | OTHER |