Healthcare Provider Details

I. General information

NPI: 1104391663
Provider Name (Legal Business Name): ON THE GO BEHAVIORAL HEALTH AND THERAPY SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/10/2018
Last Update Date: 10/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21703 STRATFORD CT
OAK PARK MI
48237-2558
US

IV. Provider business mailing address

PO BOX 820
SOUTHFIELD MI
48037-0820
US

V. Phone/Fax

Practice location:
  • Phone: 248-729-1454
  • Fax:
Mailing address:
  • Phone: 248-729-1454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: DEVHONJA MARIE TAYLOR
Title or Position: CLINICAL SOCIAL WORKER
Credential: LMSW
Phone: 248-729-1454