Provider Demographics
NPI:1578571642
Name:DIROFF, MARK LEO (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:LEO
Last Name:DIROFF
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12850 FOUNTAIN SQ
Mailing Address - Street 2:STE. 106
Mailing Address - City:DAVISBURG
Mailing Address - State:MI
Mailing Address - Zip Code:48350-2552
Mailing Address - Country:US
Mailing Address - Phone:248-634-6303
Mailing Address - Fax:248-634-1746
Practice Address - Street 1:12850 FOUNTAIN SQ
Practice Address - Street 2:STE. 106
Practice Address - City:DAVISBURG
Practice Address - State:MI
Practice Address - Zip Code:48350-2552
Practice Address - Country:US
Practice Address - Phone:248-634-6303
Practice Address - Fax:248-634-1746
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010195041041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical