Provider Demographics
NPI:1114101227
Name:SERLIN, MICHELLE IRIS (MSW)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:IRIS
Last Name:SERLIN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 W WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5131
Mailing Address - Country:US
Mailing Address - Phone:269-344-7997
Mailing Address - Fax:269-344-8642
Practice Address - Street 1:218 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49007-5131
Practice Address - Country:US
Practice Address - Phone:269-344-7997
Practice Address - Fax:269-344-8642
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-26
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010596391041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOM96560Medicare PIN