=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467528927
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JEFFREY SAMUEL NOLAN LMSW
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2006
-----------------------------------------------------
Last Update Date | 01/12/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22151 MOROSS RD PB1 STE. 334
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48236-2167
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-343-7230
-----------------------------------------------------
Fax | 313-343-7449
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28000 DEQUINDRE RD
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48092-2468
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-753-0405
-----------------------------------------------------
Fax | 586-753-0404
-----------------------------------------------------
=====================================================
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 | 6801069019
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------