Healthcare Provider Details

I. General information

NPI: 1710350715
Provider Name (Legal Business Name): CHIQUITA CARTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2015
Last Update Date: 03/26/2020
Certification Date: 03/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16124 MOROSS RD
DETROIT MI
48205-7701
US

IV. Provider business mailing address

155 S MAIN ST UNIT 848
MOUNT CLEMENS MI
48046-7700
US

V. Phone/Fax

Practice location:
  • Phone: 313-521-0180
  • Fax:
Mailing address:
  • Phone: 313-521-0180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801064578
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: