Healthcare Provider Details

I. General information

NPI: 1578150884
Provider Name (Legal Business Name): EMILY ROSE DIMPERIO LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: EMILY ROSE DIMPERIO LCSW

II. Dates (important events)

Enumeration Date: 12/22/2020
Last Update Date: 12/22/2020
Certification Date: 12/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 CHERRY ST SE APT 102
GRAND RAPIDS MI
49506-1488
US

IV. Provider business mailing address

39465 W 14 MILE RD
NOVI MI
48377-1600
US

V. Phone/Fax

Practice location:
  • Phone: 585-857-0898
  • Fax:
Mailing address:
  • Phone: 877-906-9699
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801108261
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: