Healthcare Provider Details

I. General information

NPI: 1700234416
Provider Name (Legal Business Name): ASHLEY LAUREN SANSOM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2016
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

79 W ALEXANDRINE ST
DETROIT MI
48201-2015
US

IV. Provider business mailing address

2311 HEDGE AVE
WATERFORD MI
48327-1140
US

V. Phone/Fax

Practice location:
  • Phone: 313-831-5535
  • Fax: 313-831-2608
Mailing address:
  • Phone: 248-872-6168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904019568
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW19941
License Number StateFL
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801099438
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number33839
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: