Healthcare Provider Details

I. General information

NPI: 1659729507
Provider Name (Legal Business Name): MICHIGAN DIAGNOSTIC ALCOHOL AND DRUG SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2016
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2449 E 12 MILE RD
WARREN MI
48092-5647
US

IV. Provider business mailing address

2449 E 12 MILE RD
WARREN MI
48092-5647
US

V. Phone/Fax

Practice location:
  • Phone: 586-510-4992
  • Fax: 586-393-5012
Mailing address:
  • Phone: 586-510-4992
  • Fax: 586-393-5012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: MR. KUMAR GIRI
Title or Position: OWNER
Credential:
Phone: 586-943-7390