Healthcare Provider Details

I. General information

NPI: 1811274723
Provider Name (Legal Business Name): KERAN EUDORA ERNEST LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2011
Last Update Date: 09/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 W 5TH AVE
FLINT MI
48503
US

IV. Provider business mailing address

3292 JACQUE ST
FLINT MI
48532-3709
US

V. Phone/Fax

Practice location:
  • Phone: 810-496-4913
  • Fax: 810-496-4922
Mailing address:
  • Phone: 810-810-9080
  • Fax: 810-496-4922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC-01030
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801090234
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: