Provider Demographics
NPI:1962494286
Name:VERGEL, LILLIE (LSP, LMSW, MA)
Entity Type:Individual
Prefix:
First Name:LILLIE
Middle Name:
Last Name:VERGEL
Suffix:
Gender:F
Credentials:LSP, LMSW, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 380555
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-0067
Mailing Address - Country:US
Mailing Address - Phone:586-263-1357
Mailing Address - Fax:248-746-0308
Practice Address - Street 1:45353 YORKSHIRE DR
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48044-5797
Practice Address - Country:US
Practice Address - Phone:586-263-1357
Practice Address - Fax:248-746-0308
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-23
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801015399104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker