Healthcare Provider Details

I. General information

NPI: 1104324367
Provider Name (Legal Business Name): BLUE LYTE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2018
Last Update Date: 01/19/2023
Certification Date: 01/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35115 E MICHIGAN AVE
WAYNE MI
48184-1660
US

IV. Provider business mailing address

35115 E MICHIGAN AVE
WAYNE MI
48184-1660
US

V. Phone/Fax

Practice location:
  • Phone: 248-615-3042
  • Fax: 248-615-3047
Mailing address:
  • Phone: 248-615-3042
  • Fax: 248-615-3047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State

VIII. Authorized Official

Name: PHYLLIS CLARK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 248-615-3042