Healthcare Provider Details

I. General information

NPI: 1306603493
Provider Name (Legal Business Name): AMAZU RENNIE-FORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/05/2024
Last Update Date: 03/05/2024
Certification Date: 03/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

882 OAKMAN BLVD
DETROIT MI
48238-3710
US

IV. Provider business mailing address

2211 UNIVERSITY AVE
LINCOLN PARK MI
48146-1341
US

V. Phone/Fax

Practice location:
  • Phone: 313-961-4890
  • Fax:
Mailing address:
  • Phone: 313-505-5269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851117766
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: