Healthcare Provider Details

I. General information

NPI: 1831434042
Provider Name (Legal Business Name): MAPLE CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 S UNION ST
TRAVERSE CITY MI
49684-3246
US

IV. Provider business mailing address

525 S UNION ST
TRAVERSE CITY MI
49684-3246
US

V. Phone/Fax

Practice location:
  • Phone: 231-946-9575
  • Fax: 231-947-5781
Mailing address:
  • Phone: 231-946-9575
  • Fax: 231-947-5781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateMI

VIII. Authorized Official

Name: KIMBERLY ANN CROSS
Title or Position: BUSINESS MANAGER
Credential:
Phone: 231-946-9575