Healthcare Provider Details

I. General information

NPI: 1578571642
Provider Name (Legal Business Name): MARK LEO DIROFF LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12850 FOUNTAIN SQ STE. 106
DAVISBURG MI
48350-2552
US

IV. Provider business mailing address

12850 FOUNTAIN SQ STE. 106
DAVISBURG MI
48350-2552
US

V. Phone/Fax

Practice location:
  • Phone: 248-634-6303
  • Fax: 248-634-1746
Mailing address:
  • Phone: 248-634-6303
  • Fax: 248-634-1746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801019504
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: