MEDICARE: KAMIAH OMOKAH DENIES MACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		MI

General Provider Information

NPI Number	:	1659234763
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KAMIAH OMOKAH DENIES MACK

Provider Business Mailing Address
First Line	:	14750 SAINT MARYS ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-1862
Country	:	US
Telephone Number	:	646-920-2470
Fax Number	:

Provider Business Practice Location Address
First Line	:	14750 SAINT MARYS ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-1862
Country	:	US
Telephone Number	:	646-920-2470
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/05/2025
Last Update Date	:	12/05/2025

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