Healthcare Provider Details

I. General information

NPI: 1013206341
Provider Name (Legal Business Name): BRENDA MARRON HARRIS LBSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: BRENDA MARRON MEADOWS LBSW

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 04/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20303 KELLY RD
DETROIT MI
48225-1206
US

IV. Provider business mailing address

10159 BEACONSFIELD ST
DETROIT MI
48224-2536
US

V. Phone/Fax

Practice location:
  • Phone: 313-245-7000
  • Fax: 313-245-7009
Mailing address:
  • Phone: 313-245-7000
  • Fax: 313-245-7009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802069759
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: