=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700693652
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHEILA L CROSS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/13/2024
-----------------------------------------------------
Last Update Date | 12/13/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4420 SHERIDAN ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48214-1024
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-605-1603
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 62 GRAY AVE
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11763-1094
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-428-5315
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------