MEDICARE: A SAFE PLACE COUNSELLING AND COMMUNITY SUPPORT SERVICES L3C

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	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1487280848
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A SAFE PLACE COUNSELLING AND COMMUNITY SUPPORT SERVICES L3C

Provider Business Mailing Address
First Line	:	20222 ALBANY ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-2505
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	20216 ALBANY ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-2505
Country	:	US
Telephone Number	:	313-384-4783
Fax Number	:

Authorized Official
Title or Position	:	PROFESSIONAL COUNSELOR
Name	:	TINA DIANE EALEY
Credential	:	MA
Telephone Number	:	313-384-4783

Provider Enumeration Date	:	03/18/2020
Last Update Date	:	01/03/2025

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