Provider Demographics
NPI:1336229913
Name:MCCARTHY, JAMES JOSEPH (LSMN)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:JOSEPH
Last Name:MCCARTHY
Suffix:
Gender:M
Credentials:LSMN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1604 BAGLEY ST
Mailing Address - Street 2:APT. 2
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48216-1911
Mailing Address - Country:US
Mailing Address - Phone:586-758-6670
Mailing Address - Fax:
Practice Address - Street 1:23700 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-1669
Practice Address - Country:US
Practice Address - Phone:586-758-6670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010180641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP12910Medicaid