=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609436914
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EARLY CONNECTIONS INSTITUTE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2019
-----------------------------------------------------
Last Update Date | 06/18/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13149 10 MILE RD
-----------------------------------------------------
City | SOUTH LYON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48178-9114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-845-2133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13149 10 MILE RD
-----------------------------------------------------
City | SOUTH LYON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48178-9114
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-845-2133
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST/ PROGRAM DIRECTOR
-----------------------------------------------------
Name | MRS. MONICA JULIET LAMING
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 810-845-2133
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------