Healthcare Provider Details

I. General information

NPI: 1881814812
Provider Name (Legal Business Name): GLORIA KEKALOS ALLUM M.S.W., L.M.S.W.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2007
Last Update Date: 11/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PETERBORO ST
DETROIT MI
48201-2722
US

IV. Provider business mailing address

19110 MCGILL ST
ROSEVILLE MI
48066-6907
US

V. Phone/Fax

Practice location:
  • Phone: 313-833-4622
  • Fax:
Mailing address:
  • Phone: 586-294-0026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801059009
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberC-02040
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: