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General NPI Number Information
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NPI Number | 1902279466
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Entity Type | Organization
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Legal Business Name | ST. JOHN PROVIDENCE COMMUNITY HEALTH
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Dates
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Enumeration Date | 11/05/2015
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Last Update Date | 11/18/2015
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Provider Practice Location Address
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Address Line | 11600 E 7 MILE RD
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City | DETROIT
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State | MI
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Zip | 48205-2112
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Country | US
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Telephone | 313-372-5974
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Fax |
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Provider Business Mailing Address
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Address Line | 11600 E 7 MILE RD
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City | DETROIT
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State | MI
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Zip | 48205-2112
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | BEHAVIORAL HEALTH COUNSELOR
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Name | MR. LONNIE HARVEY III
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Credential |
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Telephone | 313-372-5974
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number | 6401013184
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License Number State | MI
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