Healthcare Provider Details

I. General information

NPI: 1861306557
Provider Name (Legal Business Name): JANE ANTONCZAK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2026
Last Update Date: 09/30/2026
Certification Date: 09/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

581 TAYLOR RD
BRIGHTON MI
48114-7613
US

IV. Provider business mailing address

30490 MUNGER DR
LIVONIA MI
48154-3270
US

V. Phone/Fax

Practice location:
  • Phone: 810-626-2500
  • Fax:
Mailing address:
  • Phone: 248-719-2885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number7101001811
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: