Healthcare Provider Details

I. General information

NPI: 1356543888
Provider Name (Legal Business Name): LAVERNE DENISE MCGLOTHIAN CAC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 07/08/2007
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: 313-921-8148
Mailing address:
  • Phone: 313-415-7222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: