Healthcare Provider Details

I. General information

NPI: 1609126036
Provider Name (Legal Business Name): ANN MARIE DEAN LSW CAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANN MARIE GAUTHIER

II. Dates (important events)

Enumeration Date: 09/13/2012
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1823 COMMERCE ST
MUSKEGON MI
49441-2608
US

IV. Provider business mailing address

1823 COMMERCE ST
MUSKEGON MI
49441-2608
US

V. Phone/Fax

Practice location:
  • Phone: 231-739-6840
  • Fax: 231-722-4771
Mailing address:
  • Phone: 231-739-6840
  • Fax: 231-722-4771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1-04780
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802064466
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: