MEDICARE: EKONG COUNSELING CENTER

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	261QM0850X	Adult Mental Health Clinic/Center	6301015337	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0898217	OTHER		BCBS

General Provider Information

NPI Number	:	1477736064
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EKONG COUNSELING CENTER

Provider Business Mailing Address
First Line	:	29532 SOUTHFIELD RD
Second Line	:	101
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-2023
Country	:	US
Telephone Number	:	248-469-8322
Fax Number	:	248-423-4249

Provider Business Practice Location Address
First Line	:	29532 SOUTHFIELD RD
Second Line	:	101
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-2023
Country	:	US
Telephone Number	:	248-469-8322
Fax Number	:	248-423-4249

Authorized Official
Title or Position	:	OWNER
Name	:	LAVINIA RUCKES EKONG
Credential	:	LMSW
Telephone Number	:	248-469-8322

Provider Enumeration Date	:	12/06/2007
Last Update Date	:	02/02/2016

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