=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366133456
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANGELA NIYONSENGA LMSW PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2023
-----------------------------------------------------
Last Update Date | 05/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 142 BRIGHTON LAKE RD
-----------------------------------------------------
City | BRIGHTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48116-1738
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-243-2539
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8748 RIO VISTA ST
-----------------------------------------------------
City | BRIGHTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48116-2016
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 937-540-4767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DIRECTOR
-----------------------------------------------------
Name | ANGELA NIYONSENGA
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 937-540-4767
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------