Provider Demographics
NPI:1750939237
Name:ADDISON, CARLIE ELAINE
Entity type:Individual
Prefix:
First Name:CARLIE
Middle Name:ELAINE
Last Name:ADDISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52430 BASE ST
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-1571
Mailing Address - Country:US
Mailing Address - Phone:517-282-1552
Mailing Address - Fax:
Practice Address - Street 1:35054 23 MILE RD STE 104
Practice Address - Street 2:
Practice Address - City:NEW BALTIMORE
Practice Address - State:MI
Practice Address - Zip Code:48047-2019
Practice Address - Country:US
Practice Address - Phone:586-863-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801104843104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker