Healthcare Provider Details

I. General information

NPI: 1619987518
Provider Name (Legal Business Name): MELISSA ANN ROTARY MSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
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

15030 VICTORIA CT
SHELBY TOWNSHIP MI
48315-4457
US

V. Phone/Fax

Practice location:
  • Phone: 810-966-3598
  • Fax: 810-987-9148
Mailing address:
  • Phone: 810-966-3598
  • Fax: 810-987-9148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801087875
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: