=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700901964
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CRISTO REY COMMUNITY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2007
-----------------------------------------------------
Last Update Date | 03/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1717 N HIGH ST
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48906-4529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-372-4700
-----------------------------------------------------
Fax | 517-372-3314
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1717 N HIGH ST
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48906-4529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-372-4700
-----------------------------------------------------
Fax | 517-372-3314
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF COUNSELING
-----------------------------------------------------
Name | MR. ROBERT R POWELL
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 517-372-4700
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number | 330041
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------