Provider Demographics
NPI:1063037190
Name:MOGILEVSKY, ETHEL (LLMSW)
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:
Last Name:MOGILEVSKY
Suffix:
Gender:F
Credentials:LLMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15350 N COMMERCE DR STE 204
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1234
Mailing Address - Country:US
Mailing Address - Phone:313-550-4742
Mailing Address - Fax:
Practice Address - Street 1:15350 N COMMERCE DR STE 204
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1234
Practice Address - Country:US
Practice Address - Phone:313-550-4742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011072261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical