=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841204641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ADULT PSYCHIATRIC CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2006
-----------------------------------------------------
Last Update Date | 02/13/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17141 RYAN RD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48212-1112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-369-1717
-----------------------------------------------------
Fax | 313-369-1728
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17141 RYAN RD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48212-1112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-369-1717
-----------------------------------------------------
Fax | 313-892-0137
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF EXECUTIVE OFFICER
-----------------------------------------------------
Name | MR. WILLIAM H. PEABODY
-----------------------------------------------------
Credential | MA, CSW
-----------------------------------------------------
Telephone | 313-369-1717
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number | 1706446
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------