Healthcare Provider Details

I. General information

NPI: 1982156980
Provider Name (Legal Business Name): MERIBETH GANDY PEZDA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

959 BAKER RD SUITE 1A
DEXTER MI
48130-1593
US

IV. Provider business mailing address

959 BAKER RD SUITE 1A
DEXTER MI
48130-1593
US

V. Phone/Fax

Practice location:
  • Phone: 734-757-3103
  • Fax:
Mailing address:
  • Phone: 734-757-3103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801070819
License Number StateMI

VIII. Authorized Official

Name: MS. MERIBETH GANDY PEZDA
Title or Position: LICENSED CLINICAL SOCIAL WORKER
Credential: LMSA
Phone: 734-757-3103