Healthcare Provider Details

I. General information

NPI: 1275467557
Provider Name (Legal Business Name): MEGHAN E VIDRA LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2026
Last Update Date: 06/11/2026
Certification Date: 06/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1645 N DIXIE HWY STE 2
MONROE MI
48162-5231
US

IV. Provider business mailing address

1645 N DIXIE HWY STE 2
MONROE MI
48162-5231
US

V. Phone/Fax

Practice location:
  • Phone: 734-344-7432
  • Fax: 734-344-7431
Mailing address:
  • Phone: 734-344-7432
  • Fax: 734-344-7431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6851122233
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: