Healthcare Provider Details

I. General information

NPI: 1669614061
Provider Name (Legal Business Name): STRONG YOUTH INITIATIVE MICHIGAN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2009
Last Update Date: 03/31/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 W GRAND BLVD SUITE 106
DETROIT MI
48208-1239
US

IV. Provider business mailing address

2550 W GRAND BLVD SUITE 106
DETROIT MI
48208-1239
US

V. Phone/Fax

Practice location:
  • Phone: 678-362-9955
  • Fax: 866-379-8708
Mailing address:
  • Phone: 678-362-9955
  • Fax: 866-379-8708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT ASHFORD
Title or Position: CEO
Credential:
Phone: 804-267-1899