Provider Demographics
NPI:1194107391
Name:OVLASUK, ALICE
Entity type:Individual
Prefix:MS
First Name:ALICE
Middle Name:
Last Name:OVLASUK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ALICE
Other - Middle Name:
Other - Last Name:OVLASUK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:BS LBSW QIDP
Mailing Address - Street 1:2941 S. GULLEY
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124
Mailing Address - Country:US
Mailing Address - Phone:313-425-0109
Mailing Address - Fax:
Practice Address - Street 1:2941 S. GULLEY
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124
Practice Address - Country:US
Practice Address - Phone:313-425-0109
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-24
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802080073171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator