Healthcare Provider Details

I. General information

NPI: 1982735858
Provider Name (Legal Business Name): GUIDING LIGHT SOBER LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5613 LIVERNOIS AVE
DETROIT MI
48210-1774
US

IV. Provider business mailing address

15805 BAYLIS ST
DETROIT MI
48238-3915
US

V. Phone/Fax

Practice location:
  • Phone: 313-341-1088
  • Fax: 313-894-4602
Mailing address:
  • Phone: 313-341-1088
  • Fax: 313-894-4602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number822854
License Number StateMI

VIII. Authorized Official

Name: MR. DARRYL DEWBERRY
Title or Position: CEO
Credential: BSW
Phone: 313-341-1088