Healthcare Provider Details

I. General information

NPI: 1386826949
Provider Name (Legal Business Name): PEACE IN YOUNG LIFE CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2007
Last Update Date: 02/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15471 CLOVERLAWN ST
DETROIT MI
48238-1146
US

IV. Provider business mailing address

15471 CLOVERLAWN ST
DETROIT MI
48238-1146
US

V. Phone/Fax

Practice location:
  • Phone: 313-220-9033
  • Fax: 313-345-4358
Mailing address:
  • Phone: 706-263-2533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateMI

VIII. Authorized Official

Name: MARCHELLE MITZI GAINES
Title or Position: CEO
Credential: MSW
Phone: 313-220-9033