Healthcare Provider Details

I. General information

NPI: 1043525447
Provider Name (Legal Business Name): ANDREW DWIGHT HUMPHRIES LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2010
Last Update Date: 09/13/2022
Certification Date: 09/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 WATERMAN ST
DETROIT MI
48209-2022
US

IV. Provider business mailing address

5115 GRAYTON ST
DETROIT MI
48224-2147
US

V. Phone/Fax

Practice location:
  • Phone: 313-841-8900
  • Fax: 313-841-3756
Mailing address:
  • Phone: 313-806-6711
  • Fax: 313-885-5059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801082960
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: