Healthcare Provider Details

I. General information

NPI: 1134354434
Provider Name (Legal Business Name): MS. CARLA WHEATLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2009
Last Update Date: 05/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 E KIRBY ST
DETROIT MI
48202-4123
US

IV. Provider business mailing address

660 E KIRBY ST
DETROIT MI
48202-4123
US

V. Phone/Fax

Practice location:
  • Phone: 313-826-4479
  • Fax:
Mailing address:
  • Phone: 313-826-4479
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number61-1595624
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number61-1595624
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number61-1595624
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number61-1595624
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number61-1595624
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: