Healthcare Provider Details

I. General information

NPI: 1972644458
Provider Name (Legal Business Name): AGNES ANNE BISSETT LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AGNES ANNE GOULETTE LMSW

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 09/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 RICHARDSON ST
PORT HURON MI
48060-3548
US

IV. Provider business mailing address

1221 PINE GROVE AVE
PORT HURON MI
48060-3511
US

V. Phone/Fax

Practice location:
  • Phone: 810-984-5156
  • Fax:
Mailing address:
  • Phone: 810-985-2614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number643729
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: