Healthcare Provider Details

I. General information

NPI: 1578987624
Provider Name (Legal Business Name): ANGELA LEE MUTSCHLER I LMSW, QMHP, QMRP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2014
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

611 N STATE ST
STANTON MI
48888-9702
US

IV. Provider business mailing address

119 BELDING ST
CRYSTAL MI
48818-5100
US

V. Phone/Fax

Practice location:
  • Phone: 989-444-9806
  • Fax: 989-831-7578
Mailing address:
  • Phone: 248-672-2328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801094911
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: