Healthcare Provider Details

I. General information

NPI: 1457603292
Provider Name (Legal Business Name): MRS. CHARISSE CELESTE BOOKER-ALLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date: 06/05/2013
Reactivation Date: 02/26/2014

III. Provider practice location address

13101 ALLEN RD
SOUTHGATE MI
48195-2216
US

IV. Provider business mailing address

13101 ALLEN RD
SOUTHGATE MI
48195-2216
US

V. Phone/Fax

Practice location:
  • Phone: 734-785-7700
  • Fax: 734-287-4602
Mailing address:
  • Phone: 734-785-7700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6802065475
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number6802065475
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: