Healthcare Provider Details

I. General information

NPI: 1306868864
Provider Name (Legal Business Name): GERALD STANLEY KWAS MA LPC LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 02/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15370 LEVAN RD. #2
LIVONIA MI
48154
US

IV. Provider business mailing address

8962 PERE AVE
LIVONIA MI
48150-3339
US

V. Phone/Fax

Practice location:
  • Phone: 734-744-0170
  • Fax: 734-744-0171
Mailing address:
  • Phone: 734-744-0170
  • Fax: 734-744-0171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401004253
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801003716
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: