Provider Demographics
NPI:1689191918
Name:FANSLOW, MARY E (LLMSW)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
Last Name:FANSLOW
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 1:42488 CORLINA DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48167-3811
Mailing Address - Country:US
Mailing Address - Phone:773-243-6673
Mailing Address - Fax:
Practice Address - Street 1:8906 COMMERCE RD STE 1
Practice Address - Street 2:
Practice Address - City:COMMERCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48382-4484
Practice Address - Country:US
Practice Address - Phone:833-324-9675
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2021-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011058241041C0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program