Provider Demographics
NPI:1811274723
Name:ERNEST, KERAN EUDORA (LMSW)
Entity type:Individual
Prefix:MRS
First Name:KERAN
Middle Name:EUDORA
Last Name:ERNEST
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 1:3292 JACQUE ST
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3709
Mailing Address - Country:US
Mailing Address - Phone:810-810-9080
Mailing Address - Fax:810-496-4922
Practice Address - Street 1:420 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503
Practice Address - Country:US
Practice Address - Phone:810-496-4913
Practice Address - Fax:810-496-4922
Is Sole Proprietor?:No
Enumeration Date:2011-11-05
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-01030101YA0400X
104100000X
MI68010902341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI383469611OtherEMPLOYER EIN