Healthcare Provider Details

I. General information

NPI: 1134341092
Provider Name (Legal Business Name): NCADD-IMPACT ADOLESCENT HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2007
Last Update Date: 08/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 CONNER ST 2000 NORTH
DETROIT MI
48213-3448
US

IV. Provider business mailing address

488 FRAZIER ST
RIVER ROUGE MI
48218-1025
US

V. Phone/Fax

Practice location:
  • Phone: 313-921-8102
  • Fax: 313-921-4184
Mailing address:
  • Phone: 313-551-3815
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberC1820235935
License Number StateMI

VIII. Authorized Official

Name: MS. LAVERNE DENISE MCGLOTHIAN
Title or Position: OFFICE MANAGER
Credential: FOADP
Phone: 313-921-8102