MEDICARE: SHEILA SUE SOUTHWELL LMSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	6801078569	MI

General Provider Information

NPI Number	:	1669511382
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHEILA SUE SOUTHWELL LMSW

Provider Business Mailing Address
First Line	:	6464 MONTGOMERY RD
Second Line	:
City	:	AFTON
State	:	MI
Zip	:	49705-9714
Country	:	US
Telephone Number	:	231-238-0397
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 MACDONALD DR
Second Line	:	SUITE D
City	:	PETOSKEY
State	:	MI
Zip	:	49770-4406
Country	:	US
Telephone Number	:	231-347-9605
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2007
Last Update Date	:	07/08/2007

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