Healthcare Provider Details

I. General information

NPI: 1952701559
Provider Name (Legal Business Name): DEBRA JANE WILLISON LMSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2014
Last Update Date: 09/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

161 IDA RED AVE
SPARTA MI
49345-1715
US

IV. Provider business mailing address

161 IDA RED AVE
SPARTA MI
49345-1715
US

V. Phone/Fax

Practice location:
  • Phone: 231-689-7330
  • Fax: 231-689-7345
Mailing address:
  • Phone: 231-689-7330
  • Fax: 231-689-7345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801060783
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: