Basic Information
| Provider Information | |||||||||
| NPI: | 1407106529 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRISON | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | L.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT 781625 | ||||||||
| Address2: | P.O. BOX 78000 | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482781625 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143558004 | ||||||||
| FaxNumber: | 6143552220 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 E MAIN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432155369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6143556300 | ||||||||
| FaxNumber: | 6143556310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2012 | ||||||||
| LastUpdateDate: | 02/22/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | OH | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 390200000X | S.1200104-TRNE | OH | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 2846675 | 05 | OH | MEDICAID |