Healthcare Provider Details

I. General information

NPI: 1700901964
Provider Name (Legal Business Name): CRISTO REY COMMUNITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/20/2007
Last Update Date: 03/06/2025
Certification Date: 03/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 N HIGH ST
LANSING MI
48906-4529
US

IV. Provider business mailing address

1717 N HIGH ST
LANSING MI
48906-4529
US

V. Phone/Fax

Practice location:
  • Phone: 517-372-4700
  • Fax: 517-372-3314
Mailing address:
  • Phone: 517-372-4700
  • Fax: 517-372-3314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number330041
License Number StateMI

VIII. Authorized Official

Name: MR. ROBERT R POWELL
Title or Position: DIRECTOR OF COUNSELING
Credential: LMSW
Phone: 517-372-4700