Basic Information
| Provider Information | |||||||||
| NPI: | 1962121913 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DOUG DERDOWSKI, LMSW LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4660 MARSH RD | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488642143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175253405 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4660 MARSH RD | ||||||||
| Address2: | |||||||||
| City: | OKEMOS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488642143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175253405 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2022 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DERDOWSKI | ||||||||
| AuthorizedOfficialFirstName: | DOUG | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | SOCIAL WORKER | ||||||||
| AuthorizedOfficialTelephone: | 5175253405 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.