=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083868491
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WENDY L KOEBEL LMSW ACSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/12/2008
-----------------------------------------------------
Last Update Date | 11/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5640 W MAPLE RD SUITE 204
-----------------------------------------------------
City | WEST BLOOMFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48322-3716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-321-1953
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2430 YASMIN DR
-----------------------------------------------------
City | COMMERCE TWP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48382-5202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-321-1953
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6802074742
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------