Healthcare Provider Details

I. General information

NPI: 1831512938
Provider Name (Legal Business Name): ANQUINETTE LERICE MOSLEY MALLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 CONNER ST
DETROIT MI
48213-3448
US

IV. Provider business mailing address

5555 CONNER ST
DETROIT MI
48213-3448
US

V. Phone/Fax

Practice location:
  • Phone: 313-308-0255
  • Fax: 313-308-0270
Mailing address:
  • Phone: 313-308-0255
  • Fax: 313-308-0270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC-02311
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6301012034
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: