Healthcare Provider Details

I. General information

NPI: 1396988317
Provider Name (Legal Business Name): PATRICE CHEATHAM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16200 19 MILE RD
CLINTON TWP MI
48038-1103
US

IV. Provider business mailing address

11916 ROXBURY ST
DETROIT MI
48224-4114
US

V. Phone/Fax

Practice location:
  • Phone: 586-201-6768
  • Fax: 586-412-7889
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802074487
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: