Healthcare Provider Details

I. General information

NPI: 1609290451
Provider Name (Legal Business Name): DETROIT WAYNE MENTAL HEALTH AUTHORITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2014
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 W MILWAUKEE ST
DETROIT MI
48202-2943
US

IV. Provider business mailing address

707 W MILWAUKEE ST
DETROIT MI
48202-2943
US

V. Phone/Fax

Practice location:
  • Phone: 313-344-9099
  • Fax:
Mailing address:
  • Phone: 313-344-9090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State

VIII. Authorized Official

Name: MRS. STACIE DURANT
Title or Position: CHIEF FINANCIAL OFFICER
Credential: CPA
Phone: 313-344-9099