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General NPI Number Information
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NPI Number | 1427355049
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Entity Type | Organization
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Legal Business Name | MICHIGAN BEHAVIORAL WELLNESS LLC
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Dates
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Enumeration Date | 02/16/2011
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Last Update Date | 04/18/2011
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Provider Practice Location Address
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Address Line | 1386 E JEFFERSON AVE
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City | DETROIT
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State | MI
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Zip | 48207-3104
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Country | US
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Telephone | 313-908-0172
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Fax |
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Provider Business Mailing Address
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Address Line | 28157 DEQUINDRE RD STE 202
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City | MADISON HEIGHTS
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State | MI
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Zip | 48071-3046
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Country | US
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Telephone | 248-677-1564
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | DR. SANYANI EDWARDS
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Credential | PSY.,S.
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Telephone | 248-677-1564
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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