Healthcare Provider Details

I. General information

NPI: 1093087801
Provider Name (Legal Business Name): PROGRESS TRANSITIONALNONPROFIT HOUSING CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2012
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13500 E. MCNICHOLS ROAD
DETROIT MI
48205-3426
US

IV. Provider business mailing address

13500 E. MCNICHOLS ROAD
DETROIT MI
48205-3426
US

V. Phone/Fax

Practice location:
  • Phone: 313-647-4559
  • Fax: 313-255-3947
Mailing address:
  • Phone: 313-647-4559
  • Fax: 313-255-3947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4704276788
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number4704276788
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6801086770
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number4704276788
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4704276788
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number4704276788
License Number StateMI
# 7
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number822974
License Number StateMI

VIII. Authorized Official

Name: JUAN CLARK
Title or Position: PRESIDENT, BOARD OF DIRECTORS
Credential:
Phone: 313-350-2863