Healthcare Provider Details

I. General information

NPI: 1306243225
Provider Name (Legal Business Name): DEBRA T HURSEY-LEE BACHELOR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SANDY BEARD MSW

II. Dates (important events)

Enumeration Date: 11/20/2014
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MASSACHUSETTS ST NONE
HIGHLAND PARK MI
48203-3537
US

IV. Provider business mailing address

8627 WOODWARD AVE
DETROIT MI
48202-2141
US

V. Phone/Fax

Practice location:
  • Phone: 313-731-7133
  • Fax:
Mailing address:
  • Phone: 313-870-9372
  • Fax: 313-871-0143

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number6801081452
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: