Healthcare Provider Details

I. General information

NPI: 1174954531
Provider Name (Legal Business Name): JASON MAROUDIS LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2013
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31500 SCHOOLCRAFT RD
LIVONIA MI
48150-1805
US

IV. Provider business mailing address

6549 TOWN CENTER DR SUITE A
CLARKSTON MI
48346-4824
US

V. Phone/Fax

Practice location:
  • Phone: 734-422-9340
  • Fax: 734-422-9353
Mailing address:
  • Phone: 248-620-6400
  • Fax: 248-620-6405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801088373
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: