Healthcare Provider Details

I. General information

NPI: 1497896377
Provider Name (Legal Business Name): NIKKI R HALL-TERRY BS, CAC-1
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3840 FAIRVIEW ST
DETROIT MI
48214-1608
US

IV. Provider business mailing address

150 STIMSON ST
DETROIT MI
48201-2410
US

V. Phone/Fax

Practice location:
  • Phone: 313-331-8990
  • Fax: 313-331-6375
Mailing address:
  • Phone: 313-993-4700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: