Healthcare Provider Details

I. General information

NPI: 1689605230
Provider Name (Legal Business Name): ANN MARIE BLACKTOP LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 05/22/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 E MAIN ST
HART MI
49420-1190
US

IV. Provider business mailing address

611 E MAIN ST
HART MI
49420-1190
US

V. Phone/Fax

Practice location:
  • Phone: 231-873-5675
  • Fax: 231-873-4805
Mailing address:
  • Phone: 231-873-5675
  • Fax: 231-873-4805

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberAB033570
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: