Healthcare Provider Details

I. General information

NPI: 1700162153
Provider Name (Legal Business Name): MATINA FABIAN LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2011
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 GRISWOLD ST SUITE 3
NORTHVILLE MI
48167-2675
US

IV. Provider business mailing address

670 GRISWOLD ST SUITE 3
NORTHVILLE MI
48167-2675
US

V. Phone/Fax

Practice location:
  • Phone: 248-347-3470
  • Fax: 248-347-2242
Mailing address:
  • Phone: 248-347-3470
  • Fax: 248-347-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801093673
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: