Healthcare Provider Details

I. General information

NPI: 1295778413
Provider Name (Legal Business Name): JUDY POURCHO MSW LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 11/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16836 NEWBURGH RD
LIVONIA MI
48154-1600
US

IV. Provider business mailing address

1420 STEPHENSON HWY SUITE 400-CREDENTIALING
TROY MI
48083-1189
US

V. Phone/Fax

Practice location:
  • Phone: 734-464-4220
  • Fax: 734-464-5885
Mailing address:
  • Phone: 248-581-5971
  • Fax: 248-581-5640

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801057885
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801057885
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: