Healthcare Provider Details

I. General information

NPI: 1790873347
Provider Name (Legal Business Name): TRANSITIONAL LIFESTYLES COMMUNITY, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2006
Last Update Date: 01/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W 5TH AVE SUITE 1
FLINT MI
48503-2472
US

IV. Provider business mailing address

PO BOX 310365
FLINT MI
48531-0365
US

V. Phone/Fax

Practice location:
  • Phone: 810-908-7320
  • Fax: 810-877-6453
Mailing address:
  • Phone: 810-908-7320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801082709
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number250346
License Number StateMI

VIII. Authorized Official

Name: DEBORAH ANN BROOKS
Title or Position: DIRECTOR
Credential: LMSW, ACSW,CAAC,QSAP
Phone: 810-908-7320