=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851761704
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC HENLEY CPSS-CPRC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/05/2015
-----------------------------------------------------
Last Update Date | 09/26/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1423 FIELD ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48214-2321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-921-7860
-----------------------------------------------------
Fax | 313-921-9106
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 707 W MILWAUKEE ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48202-2943
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-344-9099
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 175T00000X
-----------------------------------------------------
Taxonomy Name | Peer Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------