Healthcare Provider Details

I. General information

NPI: 1508014960
Provider Name (Legal Business Name): JOANN J MARSACK R N C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2008
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 FIELD ST
DETROIT MI
48214-2321
US

IV. Provider business mailing address

1423 FIELD ST
DETROIT MI
48214-2321
US

V. Phone/Fax

Practice location:
  • Phone: 313-347-2070
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number545499
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: