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General NPI Number Information
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NPI Number | 1215947320
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Entity Type | Individual
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Provider Name | KENNETH J FORMOSA SR. MSW, LMSW
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Gender | Male
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Dates
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Enumeration Date | 08/09/2006
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | ROMULAS HELP CENTER 9430 WAYNE ROAD SUITE A
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City | ROAMULAS
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State | MI
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Zip | 48174
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Country | US
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Telephone | 734-942-7585
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Fax | 734-942-7977
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Provider Business Mailing Address
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Address Line | 8416 BAYTES DR
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City | BRIGHTON
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State | MI
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Zip | 48116
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Country | US
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Telephone | 734-751-5722
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | 6801069917
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License Number State | MI
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