=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932823150
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EMMANUEL HOUSE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/30/2022
-----------------------------------------------------
Last Update Date | 09/30/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14750 SAINT MARYS ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48227-1862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-397-2372
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14750 SAINT MARYS ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48227-1862
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 131-339-7237
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | TIMOTHY ARTHUR THOMPSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-397-2372
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------