Provider Demographics
NPI:1942340500
Name:SEAGLE, MIRIAM BERRY (LMSW)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:BERRY
Last Name:SEAGLE
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:MIRIAM
Other - Middle Name:
Other - Last Name:BERRY-SEAGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4372 GREENSTOWN DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48323-2725
Mailing Address - Country:US
Mailing Address - Phone:248-681-8176
Mailing Address - Fax:
Practice Address - Street 1:31700 W 13 MILE RD
Practice Address - Street 2:SUITE 219
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-2166
Practice Address - Country:US
Practice Address - Phone:248-787-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801070720104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI5323OtherMEDICARE PTAN NUMBER