Healthcare Provider Details

I. General information

NPI: 1295074433
Provider Name (Legal Business Name): LOLITA CHANDLER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2013
Last Update Date: 05/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19953 CONANT ST
DETROIT MI
48234-1334
US

IV. Provider business mailing address

19953 CONANT
DETROIT MI
48237-2535
US

V. Phone/Fax

Practice location:
  • Phone: 248-291-5801
  • Fax:
Mailing address:
  • Phone: 313-740-2672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801080545
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5501004655
License Number StateMI

VIII. Authorized Official

Name: MS. LOLITA CHANDLER
Title or Position: OWNER
Credential:
Phone: 313-368-0005