MEDICARE: MR. JOHN R DEBRUYNE II M.S.W., M.B.A

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	1041C0700X	Clinical Social Worker	I-0004362	OH

General Provider Information

NPI Number	:	1326138595
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JOHN R DEBRUYNE II M.S.W., M.B.A

Provider Business Mailing Address
First Line	:	6833 SYLVANIA PETERSBURG RD
Second Line	:
City	:	OTTAWA LAKE
State	:	MI
Zip	:	49267-9523
Country	:	US
Telephone Number	:	734-854-6207
Fax Number	:	419-824-1558

Provider Business Practice Location Address
First Line	:	6833 SYLVANIA PETERSBURG RD
Second Line	:
City	:	OTTAWA LAKE
State	:	MI
Zip	:	49267-9523
Country	:	US
Telephone Number	:	734-854-6207
Fax Number	:	419-824-1558

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/16/2006
Last Update Date	:	07/08/2007

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