MEDICARE: RENEE ANN LADRIGUE LBSW QMRP

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	104100000X	Social Worker	6802073341	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	6802073341	OTHER	MI	SOCIAL WORK LICENSE

General Provider Information

NPI Number	:	1356780340
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENEE ANN LADRIGUE LBSW QMRP

Provider Business Mailing Address
First Line	:	4688 MADISON ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48125-2366
Country	:	US
Telephone Number	:	313-999-7557
Fax Number	:

Provider Business Practice Location Address
First Line	:	4688 MADISON ST
Second Line	:
City	:	DEARBORN HEIGHTS
State	:	MI
Zip	:	48125-2366
Country	:	US
Telephone Number	:	313-999-7557
Fax Number	:

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

Provider Enumeration Date	:	06/23/2013
Last Update Date	:	06/23/2013

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