Healthcare Provider Details

I. General information

NPI: 1780097063
Provider Name (Legal Business Name): SAVANNAH SPECIALIZED ROOM & BOARD INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 06/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

169 CORTLAND ST
HIGHLAND PARK MI
48203
US

IV. Provider business mailing address

169 CORTLAND ST
HIGHLAND PARK MI
48203
US

V. Phone/Fax

Practice location:
  • Phone: 313-731-7166
  • Fax: 313-868-2282
Mailing address:
  • Phone: 313-731-7166
  • Fax: 313-868-2282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code225XM0800X
TaxonomyMental Health Occupational Therapist
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number
License Number State
# 12
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MS. TRACEE LYNN BATES
Title or Position: ADMINISTRATOR
Credential: MBA
Phone: 313-731-7166