Healthcare Provider Details

I. General information

NPI: 1700929106
Provider Name (Legal Business Name): CAROL HEYDLAUFF ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 WILDWOOD AVE
JACKSON MI
49201-1012
US

IV. Provider business mailing address

505 WILDWOOD AVE
JACKSON MI
49201-1012
US

V. Phone/Fax

Practice location:
  • Phone: 517-788-8440
  • Fax: 517-783-4504
Mailing address:
  • Phone: 517-788-8440
  • Fax: 517-783-4504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801019250
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: