=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275868077
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINDA MARIW DATI L.M.S.W.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2009
-----------------------------------------------------
Last Update Date | 10/12/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4112 OUTLOOK BLVD
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81008-1667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-466-5956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38370 MAPLE FOREST BLVD E
-----------------------------------------------------
City | HARRISON TOWNSHIP
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48045-2213
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-466-5956
-----------------------------------------------------
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 | 6801046345
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------