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NPI Code Detail

MEDICARE: MR. LARRY WILLIS COLSTON LMSW,ACSW

MEDICARE: MR. LARRY WILLIS COLSTON LMSW,ACSW
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker6801034096MI

General Provider Information

NPI Number : 1033294947
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. LARRY WILLIS COLSTON LMSW,ACSW
Provider Business Mailing Address
First Line : 10 PETERBORO ST
Second Line :
City : DETROIT
State : MI
Zip : 48201-2722
Country : US
Telephone Number : 313-831-3160
Fax Number : 313-831-2604
Provider Business Practice Location Address
First Line : 10 PETERBORO ST
Second Line :
City : DETROIT
State : MI
Zip : 48201-2722
Country : US
Telephone Number : 313-831-3160
Fax Number : 313-831-2604
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/26/2006
Last Update Date : 05/25/2012

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