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General NPI Number Information
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NPI Number | 1558107276
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Entity Type | Organization
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Legal Business Name | INNER CITY FAMILY SERVICES DETROIT LLC
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Dates
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Enumeration Date | 07/02/2024
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Last Update Date | 01/14/2025
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Provider Practice Location Address
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Address Line | 17894 MACK AVE
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City | GROSSE POINTE
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State | MI
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Zip | 48230-6250
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Country | US
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Telephone | 917-916-6801
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Fax |
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Provider Business Mailing Address
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Address Line | 17894 MACK AVE
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City | GROSSE POINTE
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State | MI
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Zip | 48230-6250
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. RAUL WIKKELING
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Credential |
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Telephone | 917-916-6801
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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