Provider Demographics
NPI:1689801334
Name:LOPER, FAUSTINIA TALISON
Entity Type:Individual
Prefix:MRS
First Name:FAUSTINIA
Middle Name:TALISON
Last Name:LOPER
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:FAUSTINIA
Other - Middle Name:MERANDA
Other - Last Name:TALISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15819 SCHOOLCRAFT ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48227-1749
Mailing Address - Country:US
Mailing Address - Phone:313-493-4900
Mailing Address - Fax:313-493-4904
Practice Address - Street 1:15819 SCHOOLCRAFT ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-1749
Practice Address - Country:US
Practice Address - Phone:313-493-4900
Practice Address - Fax:313-493-4904
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-19
Last Update Date:2009-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010148381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI237464Medicare Oscar/Certification