=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083086649
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ANN ARBOR DBT CENTER PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/22/2015
-----------------------------------------------------
Last Update Date | 10/22/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 202 E WASHINGTON ST #500
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-680-6425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 202 E WASHINGTON ST #500
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-680-6425
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TEAM LEADER/CLINICIAN
-----------------------------------------------------
Name | CAROLYN A HARTFORD
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 734-680-6425
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------