Healthcare Provider Details

I. General information

NPI: 1356407886
Provider Name (Legal Business Name): PETER HEALEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 06/12/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1122 NORTH LEROY SUITE A
FENTON MI
48430-1415
US

IV. Provider business mailing address

602 MARY COURT
FENTON MI
48430-1415
US

V. Phone/Fax

Practice location:
  • Phone: 810-240-0143
  • Fax:
Mailing address:
  • Phone: 810-240-0143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801080309
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: