Healthcare Provider Details

I. General information

NPI: 1285043406
Provider Name (Legal Business Name): DETROIT CENTRAL CITY COMMUNITY MENTAL HEALTH INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2014
Last Update Date: 07/11/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 PETERBORO ST
DETROIT MI
48201-2722
US

IV. Provider business mailing address

10 PETERBORO ST
DETROIT MI
48201-2722
US

V. Phone/Fax

Practice location:
  • Phone: 313-831-3160
  • Fax: 313-833-2604
Mailing address:
  • Phone: 313-831-3160
  • Fax: 313-826-0567

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number702008
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MICHELLE RILEY
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 313-221-8595