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General NPI Number Information
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NPI Number | 1205304359
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Entity Type | Organization
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Legal Business Name | LIFE CHALLENGE OF SOUTHEASTERN MICHIGAN
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Dates
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Enumeration Date | 11/07/2018
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Last Update Date | 11/07/2018
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Provider Practice Location Address
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Address Line | 17667 PIERSON ST
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City | DETROIT
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State | MI
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Zip | 48219-2520
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Country | US
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Telephone | 313-531-0111
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Fax |
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Provider Business Mailing Address
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Address Line | 17667 PIERSON ST
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City | DETROIT
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State | MI
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Zip | 48219-2520
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Country | US
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Telephone | 313-531-0111
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | KEN KEENE
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Credential | MDIV
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Telephone | 313-531-0111
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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