=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043837305
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN ADAM DEMOISEY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2020
-----------------------------------------------------
Last Update Date | 12/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 730 N MACOMB ST STE 200
-----------------------------------------------------
City | MONROE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48162-2904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-240-1760
-----------------------------------------------------
Fax | 734-240-1763
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 N SUMMIT ST FL 7
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43604-1531
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-324-8326
-----------------------------------------------------
Fax | 419-824-7359
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number | 6801107408
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801107408
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------