Healthcare Provider Details

I. General information

NPI: 1740573104
Provider Name (Legal Business Name): MICHAEL JAMES FARRUG MA LPC SCL LSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/18/2011
Last Update Date: 05/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 E 12 MILE RD EMERGENCY ROOM
WARREN MI
48093-3472
US

IV. Provider business mailing address

11800 E 12 MILE RD EMERGENCY ROOM
WARREN MI
48093-3472
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-5872
  • Fax:
Mailing address:
  • Phone: 586-573-5872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401002292
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number195786
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802070800
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: