Provider Demographics
NPI:1619386588
Name:PRINCE, ANGELISA (LLMSW)
Entity Type:Individual
Prefix:MRS
First Name:ANGELISA
Middle Name:
Last Name:PRINCE
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 1:11457 SHOEMAKER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-3418
Mailing Address - Country:US
Mailing Address - Phone:313-267-9600
Mailing Address - Fax:313-267-2072
Practice Address - Street 1:11457 SHOEMAKER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3418
Practice Address - Country:US
Practice Address - Phone:313-267-9600
Practice Address - Fax:313-267-2072
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010958351041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical