Healthcare Provider Details

I. General information

NPI: 1114060852
Provider Name (Legal Business Name): JUSTINA MALBOUEF LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21885 DUNHAM RD SUITE 1
CLINTON TWP MI
48036-1030
US

IV. Provider business mailing address

20450 33 MILE
ARMADA MI
48005
US

V. Phone/Fax

Practice location:
  • Phone: 586-783-8113
  • Fax:
Mailing address:
  • Phone: 586-784-5133
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802073126
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: