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General NPI Number Information
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NPI Number | 1003631987
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Entity Type | Organization
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Legal Business Name | OUTSIDETHEBOX DETROIT THERAPY
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Dates
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Enumeration Date | 11/18/2024
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Last Update Date | 11/18/2024
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Provider Practice Location Address
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Address Line | 4131 CLIPPERT ST
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City | DEARBORN HTS
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State | MI
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Zip | 48125-2732
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Country | US
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Telephone | 313-680-0019
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Fax |
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Provider Business Mailing Address
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Address Line | 23131 MICHIGAN AVE # 1046
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City | DEARBORN
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State | MI
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Zip | 48124-2020
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Country | US
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Telephone | 313-680-0019
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Fax |
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Authorized Official
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Title or Position | CEO/THERAPIST
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Name | BRADLEY ALLAN LAKE
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Credential | LMSW
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Telephone | 313-680-0019
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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