Provider Demographics
NPI:1538682786
Name:LOVE, VERENA LOUISE
Entity Type:Individual
Prefix:MRS
First Name:VERENA
Middle Name:LOUISE
Last Name:LOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 CRANE ST
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48329-3726
Mailing Address - Country:US
Mailing Address - Phone:248-673-9252
Mailing Address - Fax:
Practice Address - Street 1:2317 CRANE ST
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:MI
Practice Address - Zip Code:48329-3726
Practice Address - Country:US
Practice Address - Phone:248-673-9252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-19
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF630004770320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAF630004770OtherAFC HOME