Healthcare Provider Details

I. General information

NPI: 1861813685
Provider Name (Legal Business Name): DETROIT CENTRAL CITY COMMUNITY MENTAL HEALTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2013
Last Update Date: 12/09/2022
Certification Date: 12/15/2020
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: 313-578-6123
  • Fax:
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 Number
License Number StateMI

VIII. Authorized Official

Name: DR. KIMBERLY FARROW
Title or Position: INTERIM PRESIDENT & CEO
Credential: M.D.
Phone: 313-733-1302