Provider Demographics
NPI:1104954866
Name:DE LARA, JEREME C (SWT)
Entity type:Individual
Prefix:MR
First Name:JEREME
Middle Name:C
Last Name:DE LARA
Suffix:
Gender:M
Credentials:SWT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:555 TOWNER ST
Mailing Address - Street 2:PO BOX 915
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48198-5752
Mailing Address - Country:US
Mailing Address - Phone:734-544-3000
Mailing Address - Fax:734-544-6732
Practice Address - Street 1:2140 E ELLSWORTH RD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-2552
Practice Address - Country:US
Practice Address - Phone:734-971-2282
Practice Address - Fax:734-971-2487
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6803085297104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker