Healthcare Provider Details

I. General information

NPI: 1669770137
Provider Name (Legal Business Name): ELIZABETH DIANE STAMP LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2011
Last Update Date: 05/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15082 LAKEVIEW
FENTON MI
48430-1328
US

IV. Provider business mailing address

2215 FULLER RD
ANN ARBOR MI
48105-9922
US

V. Phone/Fax

Practice location:
  • Phone: 734-845-5500
  • Fax: 734-845-3462
Mailing address:
  • Phone: 734-649-8491
  • Fax: 734-845-3462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801091086
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: