Provider Demographics
NPI:1295408003
Name:SLOTKA, IDALIS (LLMSW)
Entity Type:Individual
Prefix:MISS
First Name:IDALIS
Middle Name:
Last Name:SLOTKA
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 1:14165 N FENTON RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48430
Mailing Address - Country:US
Mailing Address - Phone:810-845-6802
Mailing Address - Fax:
Practice Address - Street 1:14165 N FENTON RD
Practice Address - Street 2:SUITE 102
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430
Practice Address - Country:US
Practice Address - Phone:810-845-6802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-28
Last Update Date:2021-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011102621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty