Healthcare Provider Details

I. General information

NPI: 1821322454
Provider Name (Legal Business Name): THEADORE ALGER MARTIN CACM,CSOTS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8097 DECATUR ST
DETROIT MI
48228-2721
US

IV. Provider business mailing address

8097 DECATUR ST
DETROIT MI
48228-2721
US

V. Phone/Fax

Practice location:
  • Phone: 313-846-5020
  • Fax: 313-846-3468
Mailing address:
  • Phone: 313-846-5020
  • Fax: 313-846-3468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number25572CSOTS
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number104888 CACM
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: