Healthcare Provider Details

I. General information

NPI: 1104435460
Provider Name (Legal Business Name): GODDESS GREAT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2020
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17169 E WARREN AVE
DETROIT MI
48224-2279
US

IV. Provider business mailing address

10728 DUPREY ST
DETROIT MI
48224-1295
US

V. Phone/Fax

Practice location:
  • Phone: 313-856-9192
  • Fax:
Mailing address:
  • Phone: 269-414-5907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KYMALETHA BROWN
Title or Position: COORDINATOR
Credential: LLPC
Phone: 269-414-5907