Healthcare Provider Details

I. General information

NPI: 1093390262
Provider Name (Legal Business Name): GRETCHEN ALENE DECARTERET CTRS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2021
Last Update Date: 03/10/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7200 CHALLIS RD
BRIGHTON MI
48116-7411
US

IV. Provider business mailing address

8440 O'CONNELL RD
FENTON MI
48430
US

V. Phone/Fax

Practice location:
  • Phone: 810-227-0119
  • Fax:
Mailing address:
  • Phone: 517-404-0863
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number23642
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: