Healthcare Provider Details

I. General information

NPI: 1568776086
Provider Name (Legal Business Name): EXEC-U-TECH BEHAVIORAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 07/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 BEECHWOOD ST
RIVER ROUGE MI
48218-1041
US

IV. Provider business mailing address

1804 CAMPAU FARMS CIR
DETROIT MI
48207-5164
US

V. Phone/Fax

Practice location:
  • Phone: 313-386-2288
  • Fax:
Mailing address:
  • Phone: 313-475-0283
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6801091303
License Number StateMI

VIII. Authorized Official

Name: MRS. AURELIA LAFAYE KENT
Title or Position: EXECUTIVE DIRECTOR
Credential: LLMSW
Phone: 313-475-0283