MEDICARE: GOODWILL INDUSTRIES OF GREATER DETROIT

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1841599669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GOODWILL INDUSTRIES OF GREATER DETROIT

Provider Business Mailing Address
First Line	:	3111 GRAND RIVER AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48208-2962
Country	:	US
Telephone Number	:	313-964-3900
Fax Number	:	313-964-3909

Provider Business Practice Location Address
First Line	:	9622 GRAND RIVER AVE
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48204-2138
Country	:	US
Telephone Number	:	313-931-0901
Fax Number	:	313-931-0904

Authorized Official
Title or Position	:	PRESIDENT AND CEO
Name	:	MRS. LORNA G UTLEY
Credential	:
Telephone Number	:	313-557-8787

Provider Enumeration Date	:	03/18/2011
Last Update Date	:	03/18/2011

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