Provider Demographics
NPI:1902950157
Name:FIREBAUGH, LOUISE (MSW)
Entity Type:Individual
Prefix:
First Name:LOUISE
Middle Name:
Last Name:FIREBAUGH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:LOUISE
Other - Middle Name:JOHNSON
Other - Last Name:FIREBAUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMSW LCSW
Mailing Address - Street 1:902 WEST FRONT STREET
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684
Mailing Address - Country:US
Mailing Address - Phone:231-941-0943
Mailing Address - Fax:
Practice Address - Street 1:902 W FRONT ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2328
Practice Address - Country:US
Practice Address - Phone:231-941-0943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010642401041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0960057OtherBLUE CROSS BLUE SHIELD
MIMI13417Medicare UPIN