Provider Demographics
NPI:1871552463
Name:STEELE, LORRAINE WAGNER
Entity type:Individual
Prefix:
First Name:LORRAINE
Middle Name:WAGNER
Last Name:STEELE
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 1:44131 HANFORD RD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-2815
Mailing Address - Country:US
Mailing Address - Phone:734-414-0129
Mailing Address - Fax:
Practice Address - Street 1:2051 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1105
Practice Address - Country:US
Practice Address - Phone:313-961-5431
Practice Address - Fax:313-961-3324
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401006164101Y00000X
MI6801014722104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0Q26384047Medicare ID - Type Unspecified