Provider Demographics
NPI:1669770137
Name:STAMP, ELIZABETH DIANE (LMSW)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:DIANE
Last Name:STAMP
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2215 FULLER RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-9922
Mailing Address - Country:US
Mailing Address - Phone:734-649-8491
Mailing Address - Fax:734-845-3462
Practice Address - Street 1:15082 LAKEVIEW
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1328
Practice Address - Country:US
Practice Address - Phone:734-845-5500
Practice Address - Fax:734-845-3462
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-08
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010910861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIVA0506.OtherMEDICARE IDENTIFICATION NUMBER