Healthcare Provider Details

I. General information

NPI: 1124570023
Provider Name (Legal Business Name): MATTHEW LANCE LBSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/27/2016
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1217 S EUCLID AVE
BAY CITY MI
48706-3311
US

IV. Provider business mailing address

1217 S EUCLID AVE
BAY CITY MI
48706-3311
US

V. Phone/Fax

Practice location:
  • Phone: 989-667-9661
  • Fax: 989-402-1056
Mailing address:
  • Phone: 989-667-9661
  • Fax: 989-402-1056

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802060388
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: