Healthcare Provider Details

I. General information

NPI: 1962494286
Provider Name (Legal Business Name): LILLIE VERGEL LSP, LMSW, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2005
Last Update Date: 11/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45353 YORKSHIRE DR
MACOMB MI
48044-5797
US

IV. Provider business mailing address

PO BOX 380555
CLINTON TOWNSHIP MI
48038-0067
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-1357
  • Fax: 248-746-0308
Mailing address:
  • Phone: 586-263-1357
  • Fax: 248-746-0308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801015399
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: