Healthcare Provider Details

I. General information

NPI: 1780980318
Provider Name (Legal Business Name): CONTINUOUS INDEPENDENCE PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2011
Last Update Date: 01/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 N FRANCIS AVE
PONTIAC MI
48342-2721
US

IV. Provider business mailing address

28 N FRANCIS AVE
PONTIAC MI
48342-2721
US

V. Phone/Fax

Practice location:
  • Phone: 248-499-8022
  • Fax:
Mailing address:
  • Phone: 248-499-8022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number6401011745
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number6401011745
License Number StateMI

VIII. Authorized Official

Name: MR. DAVID COLEMAN
Title or Position: CLINICAL DIRECTOR
Credential: LLPC
Phone: 313-929-3422