MEDICARE: CENTRIA HEALTHCARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	247200000X	Other Technician		MI

General Provider Information

NPI Number	:	1144672650
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTRIA HEALTHCARE

Provider Business Mailing Address
First Line	:	17591 SANTA ROSA DR
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48221-2644
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	17591 SANTA ROSA DR
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48221-2644
Country	:	US
Telephone Number	:	313-205-9490
Fax Number	:

Authorized Official
Title or Position	:	BEHAVIORAL TECHNICIAN
Name	:	MONNISE JENNINGS
Credential	:
Telephone Number	:	313-205-9490

Provider Enumeration Date	:	07/08/2016
Last Update Date	:	07/21/2022

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Directions to “CENTRIA HEALTHCARE ” Practice Location

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