Healthcare Provider Details

I. General information

NPI: 1285769018
Provider Name (Legal Business Name): RALPH FENTON KANAAR LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

789 N CLARE AVE
HARRISON MI
48625-9194
US

IV. Provider business mailing address

4969 E SHORE DR
ALGER MI
48610-9646
US

V. Phone/Fax

Practice location:
  • Phone: 989-539-2141
  • Fax: 989-539-2143
Mailing address:
  • Phone: 989-345-5259
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801010053
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: