MEDICARE: MS. CAROL BLAIR-HOUSTON RN; MSW;CAADC-M

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	163W00000X	Registered Nurse	4704266843	MI
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	4704266843	MI

General Provider Information

NPI Number	:	1699142778
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CAROL BLAIR-HOUSTON RN; MSW;CAADC-M

Provider Business Mailing Address
First Line	:	16821 MARK TWAIN ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48235-4066
Country	:	US
Telephone Number	:	313-999-8724
Fax Number	:	313-370-5660

Provider Business Practice Location Address
First Line	:	39880 VAN DYKE AVE STE 202A
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48313-4670
Country	:	US
Telephone Number	:	313-999-8724
Fax Number	:	313-370-5660

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

Provider Enumeration Date	:	08/25/2015
Last Update Date	:	03/17/2026

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