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General NPI Number Information
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NPI Number | 1073062725
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Entity Type | Organization
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Legal Business Name | MISSIONARY SERVANTS OF DIVINE PROVIDENCE
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Dates
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Enumeration Date | 09/22/2016
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Last Update Date | 03/08/2017
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Provider Practice Location Address
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Address Line | 26629 HOPKINS ST
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City | INKSTER
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State | MI
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Zip | 48141-3111
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Country | US
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Telephone | 734-560-5014
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Fax | 313-633-9510
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Provider Business Mailing Address
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Address Line | 4101 MOORE ST
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City | INKSTER
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State | MI
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Zip | 48141-3017
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Country | US
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Telephone | 734-560-5014
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Fax | 313-633-9510
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Authorized Official
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Title or Position | ADMINISTRATOR/ DIRECTOR
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Name | JUSTINA E UDEAGHA
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Credential |
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Telephone | 734-560-5014
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801084613
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | 6801084613
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License Number State | MI
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