Healthcare Provider Details

I. General information

NPI: 1831214485
Provider Name (Legal Business Name): CHASIDY COLLEEN SUMMER FOGG M.A. LLP LPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHASIDY COLLEEN SUMMER ADAMS MA LLP LPC

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 12/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4287 RACE RD
LESLIE MI
49251-9446
US

IV. Provider business mailing address

4287 RACE RD
LESLIE MI
49251-9446
US

V. Phone/Fax

Practice location:
  • Phone: 517-712-7204
  • Fax: 517-796-4561
Mailing address:
  • Phone: 517-712-7204
  • Fax: 517-796-4561

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401010112
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301013308
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: