Provider Demographics
NPI:1174983639
Name:BISHAW, IVAN ARTHUR JR (MS LBSW)
Entity type:Individual
Prefix:MR
First Name:IVAN
Middle Name:ARTHUR
Last Name:BISHAW
Suffix:JR
Gender:M
Credentials:MS LBSW
Other - Prefix:MR
Other - First Name:IVAN
Other - Middle Name:ARTHUR
Other - Last Name:BISHAW
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:MS LBSW
Mailing Address - Street 1:1025 E FOREST AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-1024
Mailing Address - Country:US
Mailing Address - Phone:313-213-5070
Mailing Address - Fax:
Practice Address - Street 1:1025 E FOREST AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1024
Practice Address - Country:US
Practice Address - Phone:313-213-5260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-26
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802068733104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker