=====================================================
General NPI Number Information
=====================================================
NPI Number | 1619350808
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELMHURST HOME INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/07/2015
-----------------------------------------------------
Last Update Date | 07/07/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28762 FRANKLIN RIVER DR APT 306
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-5441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-618-3357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28762 FRANKLIN RIVER DR APT 306
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-5441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-618-3357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COUNSELOR
-----------------------------------------------------
Name | BRENDA A SMITH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-867-1090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------