Provider Demographics
NPI:1619086329
Name:INSIDIOSO, NANCY ANN (LMSW)
Entity Type:Individual
Prefix:MS
First Name:NANCY
Middle Name:ANN
Last Name:INSIDIOSO
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 1:801 HAZEN STREET
Mailing Address - Street 2:SUITE C PO BOX 249
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0249
Mailing Address - Country:US
Mailing Address - Phone:269-657-5574
Mailing Address - Fax:269-657-3474
Practice Address - Street 1:1007 E WELLS STREET
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-9612
Practice Address - Country:US
Practice Address - Phone:269-637-5297
Practice Address - Fax:269-637-9238
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
H06346028Medicare PIN