Healthcare Provider Details

I. General information

NPI: 1164571824
Provider Name (Legal Business Name): OAKWOOD YOUNG PROGRAMS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 10/21/2021
Certification Date: 10/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25650 OUTER DR
LINCOLN PARK MI
48146-2096
US

IV. Provider business mailing address

26901 BEAUMONT BLVD COMPLIANCE
SOUTHFIELD MI
48033-3849
US

V. Phone/Fax

Practice location:
  • Phone: 313-594-1510
  • Fax:
Mailing address:
  • Phone: 947-522-1964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0008X
TaxonomyPediatric Neurodevelopmental Disabilities Physician
License Number
License Number State

VIII. Authorized Official

Name: LEE ANN ODOM
Title or Position: PRESIDENT SHARED SERVICES
Credential:
Phone: 947-522-3326