Healthcare Provider Details

I. General information

NPI: 1487769790
Provider Name (Legal Business Name): AMY SUE DELANGE LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2875 HENRY ST
PORT HURON MI
48060-2526
US

IV. Provider business mailing address

5093 STATE RD
FORT GRATIOT MI
48059-2909
US

V. Phone/Fax

Practice location:
  • Phone: 810-987-9700
  • Fax:
Mailing address:
  • Phone: 810-385-6744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801068999
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: