MEDICARE: CALDWELL-THOMPSON MANOR

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	1041C0700X	Clinical Social Worker	6801058450	MI

General Provider Information

NPI Number	:	1639386907
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CALDWELL-THOMPSON MANOR

Provider Business Mailing Address
First Line	:	618 HARMON ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48202-1332
Country	:	US
Telephone Number	:	313-924-9485
Fax Number	:	313-924-9494

Provider Business Practice Location Address
First Line	:	618 HARMON ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48202-1332
Country	:	US
Telephone Number	:	313-924-9485
Fax Number	:	313-924-9494

Authorized Official
Title or Position	:	CEO
Name	:	LOUISA THOMPSON
Credential	:	LMSW
Telephone Number	:	586-757-2357

Provider Enumeration Date	:	05/17/2007
Last Update Date	:	07/26/2007

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