Healthcare Provider Details

I. General information

NPI: 1770564700
Provider Name (Legal Business Name): DIANE BETH VANLOOCKE LMSW ACSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 01/06/2023
Certification Date: 01/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 S MAUMEE ST
TECUMSEH MI
49286-2033
US

IV. Provider business mailing address

308 S MAUMEE ST
TECUMSEH MI
49286-2033
US

V. Phone/Fax

Practice location:
  • Phone: 577-423-6889
  • Fax: 577-423-6890
Mailing address:
  • Phone: 577-423-6889
  • Fax: 577-423-6890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801046406
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: