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General NPI Number Information
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NPI Number | 1568040798
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Entity Type | Organization
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Legal Business Name | YOUR GOODVILLAGE COLLECTIVE
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Dates
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Enumeration Date | 03/30/2021
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Last Update Date | 04/06/2021
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Provider Practice Location Address
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Address Line | 12811 HEMINGWAY
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City | REDFORD
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State | MI
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Zip | 48239-4606
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Country | US
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Telephone | 888-357-2366
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Fax | 888-357-2366
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Provider Business Mailing Address
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Address Line | 12811 HEMINGWAY
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City | REDFORD
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State | MI
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Zip | 48239-4606
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Country | US
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Telephone | 313-510-7003
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Fax |
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Authorized Official
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Title or Position | FOUNDING EXECUTIVE DIRECTOR
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Name | MRS. ANJANETTE DAVENPORT HATTER
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Credential | LMSW
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Telephone | 313-510-7003
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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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 | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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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 | 251K00000X
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Taxonomy Name | Public Health or Welfare Agency
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License Number |
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License Number State |
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