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General NPI Number Information
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NPI Number | 1821507740
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Entity Type | Individual
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Provider Name | MAEOLA BRUNSON-DACUS LMSW
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Gender | Female
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Dates
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Enumeration Date | 09/22/2017
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Last Update Date | 09/22/2017
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Provider Practice Location Address
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Address Line | 19321 W CHICAGO ST
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City | DETROIT
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State | MI
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Zip | 48228-1739
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Country | US
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Telephone | 877-267-3791
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Fax |
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Provider Business Mailing Address
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Address Line | 16700 PLAINVIEW AVE
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City | DETROIT
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State | MI
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Zip | 48219-3364
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Country | US
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Telephone | 313-333-6311
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801011686
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License Number State | MI
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