Healthcare Provider Details

I. General information

NPI: 1629316815
Provider Name (Legal Business Name): LIFE SKILLS VILLAGE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2013
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25900 GREENFIELD RD SUITE 100
OAK PARK MI
48237-1292
US

IV. Provider business mailing address

20010 FARMINGTON RD
LIVONIA MI
48152-1408
US

V. Phone/Fax

Practice location:
  • Phone: 248-788-4300
  • Fax: 248-605-8099
Mailing address:
  • Phone: 248-788-4300
  • Fax: 248-605-8099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberD31065
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. NATE GARDIN
Title or Position: COO
Credential:
Phone: 248-788-4300