Healthcare Provider Details

I. General information

NPI: 1609781020
Provider Name (Legal Business Name): IVAN PLEWS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23800 NORTHWESTERN HWY STE 190L
SOUTHFIELD MI
48075-7740
US

IV. Provider business mailing address

36081 GRAND RIVER AVE APT 203
FARMINGTON MI
48335-3035
US

V. Phone/Fax

Practice location:
  • Phone: 124-890-0216
  • Fax:
Mailing address:
  • Phone: 231-519-1263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: