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General NPI Number Information
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NPI Number | 1982460234
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Entity Type | Organization
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Legal Business Name | STREET LIFE RECOVERY PROGRAM
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Dates
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Enumeration Date | 02/26/2024
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Last Update Date | 08/07/2025
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Provider Practice Location Address
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Address Line | 14703 ALLEN RD STE 104
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City | SOUTHGATE
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State | MI
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Zip | 48195-2594
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Country | US
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Telephone | 734-496-5599
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Fax |
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Provider Business Mailing Address
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Address Line | 14703 ALLEN RD STE 104
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City | SOUTHGATE
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State | MI
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Zip | 48195-2594
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Country | US
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Telephone | 734-262-2753
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | EDWARD IAN ROBINSON
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Credential | PEER SUPPORT
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Telephone | 734-262-2753
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0801X
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Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
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License Number |
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License Number State |
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