Healthcare Provider Details

I. General information

NPI: 1235363698
Provider Name (Legal Business Name): CALDWELL THOMPSON MANOR INTERNATIONAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2009
Last Update Date: 05/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8537 VAN DYKE ST
DETROIT MI
48213-2374
US

IV. Provider business mailing address

23636 CUNNINGHAM AVE
WARREN MI
48091-3181
US

V. Phone/Fax

Practice location:
  • Phone: 313-924-9478
  • Fax: 313-924-9494
Mailing address:
  • Phone: 313-924-9478
  • Fax: 313-924-9494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801061937
License Number StateMI

VIII. Authorized Official

Name: MS. PATRICIA GIBBS
Title or Position: MANAGER
Credential: LMSW, ACSW
Phone: 313-924-9478