Healthcare Provider Details

I. General information

NPI: 1902717994
Provider Name (Legal Business Name): HICKORY HOLLOW II SPECIALIZED RESIDENTIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2026
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6485 HICKORY HOLLOW CT
FLINT MI
48532-2055
US

IV. Provider business mailing address

3060 S DYE RD
FLINT MI
48507-1078
US

V. Phone/Fax

Practice location:
  • Phone: 833-478-9464
  • Fax:
Mailing address:
  • Phone: 833-478-9464
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE BERTRAM
Title or Position: LICENSEE/DESIGNEE
Credential:
Phone: 833-478-9464