MEDICARE: MEDICAL FAMILY THERAPY LLC

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
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	4704156640	MI

General Provider Information

NPI Number	:	1043453541
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEDICAL FAMILY THERAPY LLC

Provider Business Mailing Address
First Line	:	818 STATE ST
Second Line	:
City	:	BOYNE CITY
State	:	MI
Zip	:	49712-9179
Country	:	US
Telephone Number	:	231-578-2006
Fax Number	:

Provider Business Practice Location Address
First Line	:	818 STATE ST
Second Line	:
City	:	BOYNE CITY
State	:	MI
Zip	:	49712-9179
Country	:	US
Telephone Number	:	231-578-2006
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MS. LAURIE A ANGER
Credential	:	PMHNP-BC
Telephone Number	:	231-578-2006

Provider Enumeration Date	:	04/13/2009
Last Update Date	:	04/13/2009

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