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General NPI Number Information
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NPI Number | 1154472710
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Entity Type | Organization
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Legal Business Name | BOYS & GIRLS REPUBLIC
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Dates
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Enumeration Date | 01/12/2007
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Last Update Date | 09/11/2025
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Provider Practice Location Address
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Address Line | 28000 W 9 MILE RD
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City | FARMINGTON HILLS
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State | MI
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Zip | 48336-3812
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Country | US
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Telephone | 248-476-9550
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Fax | 248-473-6332
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Provider Business Mailing Address
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Address Line | 28000 W 9 MILE RD
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City | FARMINGTON HILLS
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State | MI
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Zip | 48336-3812
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Country | US
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Telephone | 248-476-9550
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Fax | 248-473-6332
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | MARYJANE PECK
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Credential | LMSW
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Telephone | 248-476-9550
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 322D00000X
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Taxonomy Name | Emotionally Disturbed Childrens' Residential Treatment Facility
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License Number | C1630200987
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 251V00000X
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Taxonomy Name | Voluntary or Charitable Agency
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License Number |
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License Number State | MI
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