Healthcare Provider Details

I. General information

NPI: 1083096879
Provider Name (Legal Business Name): CARYETTE FENNER LBSW, QIDP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2015
Last Update Date: 06/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2140 E ELLSWORTH RD
ANN ARBOR MI
48108-2552
US

IV. Provider business mailing address

555 TOWNER ST P.O. BOX 915
YPSILANTI MI
48198-5752
US

V. Phone/Fax

Practice location:
  • Phone: 734-222-3433
  • Fax: 734-222-3461
Mailing address:
  • Phone: 734-544-3000
  • Fax: 734-544-6732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802081466
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: