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General NPI Number Information
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NPI Number | 1104435460
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Entity Type | Organization
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Legal Business Name | GODDESS GREAT
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Dates
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Enumeration Date | 07/23/2020
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Last Update Date | 01/20/2022
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Provider Practice Location Address
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Address Line | 17169 E WARREN AVE
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City | DETROIT
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State | MI
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Zip | 48224-2279
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Country | US
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Telephone | 313-856-9192
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Fax |
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Provider Business Mailing Address
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Address Line | 10728 DUPREY ST
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City | DETROIT
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State | MI
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Zip | 48224-1295
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Country | US
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Telephone | 269-414-5907
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Fax |
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Authorized Official
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Title or Position | COORDINATOR
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Name | KYMALETHA BROWN
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Credential | LLPC
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Telephone | 269-414-5907
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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