Provider Demographics
NPI:1326446519
Name:O'DEA, DEANNA (LMSW)
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:
Last Name:O'DEA
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:640 GRISWOLD ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-1690
Mailing Address - Country:US
Mailing Address - Phone:248-348-1100
Mailing Address - Fax:248-348-3410
Practice Address - Street 1:640 GRISWOLD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48167-1690
Practice Address - Country:US
Practice Address - Phone:248-348-1100
Practice Address - Fax:248-348-3410
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-20
Last Update Date:2014-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010338971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1801083183OtherGROUP NPI
MI382695674OtherCLINIC TAX ID