Healthcare Provider Details

I. General information

NPI: 1912146366
Provider Name (Legal Business Name): MAUREEN MCKINLEY LIGHT MSW, ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2009
Last Update Date: 02/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18090 MACK AVE
GROSSE POINTE MI
48230-6251
US

IV. Provider business mailing address

18090 MACK AVE
GROSSE POINTE MI
48230-6251
US

V. Phone/Fax

Practice location:
  • Phone: 313-640-7762
  • Fax: 313-216-2888
Mailing address:
  • Phone: 313-640-7762
  • Fax: 313-216-2888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6801019009
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: