Provider Demographics
NPI:1609607050
Name:FOSMORE, ELIJAH DEAN
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:DEAN
Last Name:FOSMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5499 E HAZEL LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-6908
Mailing Address - Country:US
Mailing Address - Phone:989-854-6710
Mailing Address - Fax:
Practice Address - Street 1:1524 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-2933
Practice Address - Country:US
Practice Address - Phone:989-854-8334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician