Healthcare Provider Details

I. General information

NPI: 1033098959
Provider Name (Legal Business Name): PHOENIX ANTTIWON BELL BA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2025
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19401 NORTHLINE RD
SOUTHGATE MI
48195-2277
US

IV. Provider business mailing address

15743 GARRISON LN
SOUTHGATE MI
48195-2640
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7700
  • Fax:
Mailing address:
  • Phone: 734-931-2106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6851122293
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: