Healthcare Provider Details

I. General information

NPI: 1376968461
Provider Name (Legal Business Name): EASTER SEALS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2014
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24445 NORTHWESTERN HWY SUITE 100
SOUTHFIELD MI
48075-6501
US

IV. Provider business mailing address

24445 NORTHWESTERN HWY SUITE 100
SOUTHFIELD MI
48075-6501
US

V. Phone/Fax

Practice location:
  • Phone: 248-483-7804
  • Fax: 248-483-7868
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6301015758
License Number StateMI

VIII. Authorized Official

Name: SHAYLA GLASS
Title or Position: BEHAVIORAL HEALTH CLINICIAN
Credential:
Phone: 248-763-2399