Provider Demographics
NPI:1932181922
Name:OWEN, MARY (CSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:OWEN
Suffix:
Gender:F
Credentials:CSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 SAINT CLAIR RIVER DR
Mailing Address - Street 2:
Mailing Address - City:ALGONAC
Mailing Address - State:MI
Mailing Address - Zip Code:48001-1802
Mailing Address - Country:US
Mailing Address - Phone:810-794-4982
Mailing Address - Fax:810-794-4407
Practice Address - Street 1:555 SAINT CLAIR RIVER DR
Practice Address - Street 2:
Practice Address - City:ALGONAC
Practice Address - State:MI
Practice Address - Zip Code:48001-1802
Practice Address - Country:US
Practice Address - Phone:810-794-4982
Practice Address - Fax:810-794-4407
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010816161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP16320001Medicare ID - Type Unspecified