Healthcare Provider Details

I. General information

NPI: 1427867340
Provider Name (Legal Business Name): CHILDREN AND YOUNG ADULT SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2025
Last Update Date: 01/06/2025
Certification Date: 01/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39514 ROCKCREST LN
NORTHVILLE MI
48168-3960
US

IV. Provider business mailing address

47526 CLIPPER ST UNIT 1254
PLYMOUTH MI
48170-7166
US

V. Phone/Fax

Practice location:
  • Phone: 810-494-1673
  • Fax:
Mailing address:
  • Phone: 810-494-1673
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name: JENNIFER SIBERT
Title or Position: PRESIDENT
Credential:
Phone: 248-910-7396