Healthcare Provider Details

I. General information

NPI: 1205929536
Provider Name (Legal Business Name): DIANNE BARBARA HARTMAN LMSW, MAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2006
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19291 NORTHLINE RD
SOUTHGATE MI
48195
US

IV. Provider business mailing address

41304 LEHIGH LN
NORTHVILLE MI
48167-1927
US

V. Phone/Fax

Practice location:
  • Phone: 734-287-1500
  • Fax: 734-287-1660
Mailing address:
  • Phone: 248-229-3884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801062132
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: