=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194838599
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNETTE LOUISE FORTINO LCSW ACSW CAC-II
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2006
-----------------------------------------------------
Last Update Date | 03/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1535 INDUSTRIAL PARK DR
-----------------------------------------------------
City | HART
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49420-8377
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-231-6550
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 10
-----------------------------------------------------
City | MASON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48854
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-676-9788
-----------------------------------------------------
Fax | 517-676-3438
-----------------------------------------------------
=====================================================
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 | 6801035655
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------