Healthcare Provider Details

I. General information

NPI: 1508322983
Provider Name (Legal Business Name): AMY CRESENTIA MRAZEK LLMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2019
Last Update Date: 02/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 LOVERS LN STE 200
PORTAGE MI
49002-1579
US

IV. Provider business mailing address

9337 BIG ROCK DR
KALAMAZOO MI
49009-9308
US

V. Phone/Fax

Practice location:
  • Phone: 800-676-0423
  • Fax: 269-441-1234
Mailing address:
  • Phone: 810-614-7065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6801103344
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: