=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396020483
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANNA C. LICAVOLI LLMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2011
-----------------------------------------------------
Last Update Date | 01/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24445 NORTHWESTERN HWY STE 200
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-2437
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-850-1998
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1951 KENMORE DR
-----------------------------------------------------
City | GROSSE POINTE WOODS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48236-1931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-635-3921
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | 6851093398
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------