=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174348247
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE GOLDEN ROOM CHILDREN'S MENTAL HEALTH SERVICES, LLC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/22/2024
-----------------------------------------------------
Last Update Date | 03/31/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6006 YORKSHIRE RD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48224-3826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-220-8777
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2222 W GRAND RIVER AVE STE A
-----------------------------------------------------
City | OKEMOS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48864-1604
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-241-6903
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DORAH KRISTINE CARTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 989-280-6095
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0855X
-----------------------------------------------------
Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------