=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134471733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTERSEALS MORC HEALTH CARE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2012
-----------------------------------------------------
Last Update Date | 10/01/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 22170 W 9 MILE RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48033-6007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-372-6800
-----------------------------------------------------
Fax | 248-355-1402
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22170 W 9 MILE RD
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48033-6007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-372-6800
-----------------------------------------------------
Fax | 248-355-1402
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT & CEO
-----------------------------------------------------
Name | BRENT WIRTH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-475-6300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------