=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396885224
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARILYN S SYTSMA LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/08/2007
-----------------------------------------------------
Last Update Date | 08/07/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 112 S 1ST AVE
-----------------------------------------------------
City | ALPENA
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49707-2812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-358-9393
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5574 BAY SHORE DR
-----------------------------------------------------
City | PRESQUE ISLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49777-8465
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-595-3282
-----------------------------------------------------
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 | 6801066322
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------