Basic Information
| Provider Information | |||||||||
| NPI: | 1316931199 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SYLVAIN | ||||||||
| FirstName: | MARIANNE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MALLP | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 428 | ||||||||
| Address2: | |||||||||
| City: | OWOSSO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488670428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897236791 | ||||||||
| FaxNumber: | 9897255061 | ||||||||
| Practice Location | |||||||||
| Address1: | 1555 INDUSTRIAL DR | ||||||||
| Address2: | |||||||||
| City: | OWOSSO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488679775 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897236791 | ||||||||
| FaxNumber: | 9897255061 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 08/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103T00000X | 6361003592 | MI | Y | Behavioral Health & Social Service Providers | Psychologist |
ID Information
| ID | Type | State | Issuer | Description | 01006119 | 01 | MI | HEALTHPLUS OF MICHIGAN | OTHER | 0P108958490 | 01 | MI | BCBS | OTHER |