Provider Demographics
NPI:1174746820
Name:DATE, ANN LOUISE (PSYD)
Entity type:Individual
Prefix:DR
First Name:ANN
Middle Name:LOUISE
Last Name:DATE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2875
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48641-2875
Mailing Address - Country:US
Mailing Address - Phone:989-832-2165
Mailing Address - Fax:
Practice Address - Street 1:720 W WACKERLY ST
Practice Address - Street 2:SUITE 4
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2769
Practice Address - Country:US
Practice Address - Phone:989-832-2165
Practice Address - Fax:989-839-4376
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2021-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301009535103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION15630Medicare ID - Type Unspecified