Healthcare Provider Details

I. General information

NPI: 1689762361
Provider Name (Legal Business Name): RAYMOND LEE MILLSAP LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 E SANILAC RD
SANDUSKY MI
48471-1383
US

IV. Provider business mailing address

4610 FISHER RD
JEDDO MI
48032-8513
US

V. Phone/Fax

Practice location:
  • Phone: 810-648-9395
  • Fax:
Mailing address:
  • Phone: 810-327-0084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberL799677
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: