Healthcare Provider Details

I. General information

NPI: 1184569659
Provider Name (Legal Business Name): REAL IMPACT BEHAVIORAL HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29623 NORTHWESTERN HWY STE 6
SOUTHFIELD MI
48034-1076
US

IV. Provider business mailing address

628 PINGREE ST
DETROIT MI
48202-2024
US

V. Phone/Fax

Practice location:
  • Phone: 313-920-9046
  • Fax: 313-731-1991
Mailing address:
  • Phone: 313-920-9046
  • Fax: 313-731-1991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. DOROTHEA FOSTER
Title or Position: CEO
Credential: LPC
Phone: 313-920-9046