Healthcare Provider Details

I. General information

NPI: 1073924585
Provider Name (Legal Business Name): MATRIX HUMAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 04/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PARSONS ST
DETROIT MI
48201-2002
US

IV. Provider business mailing address

120 PARSONS ST
DETROIT MI
48201-2002
US

V. Phone/Fax

Practice location:
  • Phone: 313-831-1000
  • Fax:
Mailing address:
  • Phone: 313-831-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number4301088119
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: DR. MARCELLA WILSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: PH.D.
Phone: 313-831-1000