Healthcare Provider Details

I. General information

NPI: 1679241277
Provider Name (Legal Business Name): MIA MATTHEWS PEER SUPPORT SPECIAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2021
Last Update Date: 08/31/2021
Certification Date: 08/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 E MCNICHOLS RD
DETROIT MI
48203-2857
US

IV. Provider business mailing address

6685 LARK ST
DETROIT MI
48213-2300
US

V. Phone/Fax

Practice location:
  • Phone: 313-365-3100
  • Fax: 313-365-3101
Mailing address:
  • Phone: 313-687-3965
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: