Healthcare Provider Details

I. General information

NPI: 1548615818
Provider Name (Legal Business Name): VICTORY CLINICAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2016
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 LANSING AVE
JACKSON MI
49202-1621
US

IV. Provider business mailing address

3300 LANSING AVE
JACKSON MI
49202-1621
US

V. Phone/Fax

Practice location:
  • Phone: 517-784-2929
  • Fax:
Mailing address:
  • Phone: 517-784-2929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name: MRS. MELISSA ANN EHART
Title or Position: CLINICAL SUPERVISIOR
Credential: LPC, CAADC
Phone: 517-784-2929