Provider Demographics
NPI:1609126036
Name:DEAN, ANN MARIE (LSW CAC)
Entity type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:DEAN
Suffix:
Gender:F
Credentials:LSW CAC
Other - Prefix:
Other - First Name:ANN
Other - Middle Name:MARIE
Other - Last Name:GAUTHIER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1823 COMMERCE ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49441-2608
Mailing Address - Country:US
Mailing Address - Phone:231-739-6840
Mailing Address - Fax:231-722-4771
Practice Address - Street 1:1823 COMMERCE ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49441-2608
Practice Address - Country:US
Practice Address - Phone:231-739-6840
Practice Address - Fax:231-722-4771
Is Sole Proprietor?:No
Enumeration Date:2012-09-13
Last Update Date:2014-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X
MI1-04780101YA0400X
MI6802064466104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No172V00000XOther Service ProvidersCommunity Health Worker
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI6802064466OtherSTATE OF MICHIGAN SOCIAL WORKER LISCENSE
MI1-04708OtherCERTIFIED ADDICTION COUNSELOR