Healthcare Provider Details

I. General information

NPI: 1285267039
Provider Name (Legal Business Name): LAUREL BEDORE LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2020
Last Update Date: 02/20/2021
Certification Date: 01/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

389 W OTIS AVE
HAZEL PARK MI
48030-1730
US

IV. Provider business mailing address

389 W OTIS AVE
HAZEL PARK MI
48030-1730
US

V. Phone/Fax

Practice location:
  • Phone: 989-325-1287
  • Fax:
Mailing address:
  • Phone: 989-325-1287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801097181
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: