Healthcare Provider Details

I. General information

NPI: 1114833662
Provider Name (Legal Business Name): SERITA HARTLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2026
Last Update Date: 08/24/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21631 TIMBERIDGE ST
SAINT CLAIR SHORES MI
48082-1285
US

IV. Provider business mailing address

21631 TIMBERIDGE ST
SAINT CLAIR SHORES MI
48082-1285
US

V. Phone/Fax

Practice location:
  • Phone: 313-417-6552
  • Fax:
Mailing address:
  • Phone: 313-417-6552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License NumberR263762630182
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: