Healthcare Provider Details

I. General information

NPI: 1659468882
Provider Name (Legal Business Name): KATIE EDWARDS HOUSE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8635 W 7 MILE RD
DETROIT MI
48221-2041
US

IV. Provider business mailing address

8635 W 7 MILE RD
DETROIT MI
48221-2041
US

V. Phone/Fax

Practice location:
  • Phone: 313-341-4323
  • Fax: 313-341-4323
Mailing address:
  • Phone: 313-341-4323
  • Fax: 313-341-4323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateMI

VIII. Authorized Official

Name: MS. GAIL C HAIGHT
Title or Position: LICENSEE
Credential: LBSW
Phone: 313-341-4323