Basic Information
| Provider Information | |||||||||
| NPI: | 1003003617 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OAKLAND FAMILY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 ORCHARD LAKE ROAD | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48341 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488587766 | ||||||||
| FaxNumber: | 2488587201 | ||||||||
| Practice Location | |||||||||
| Address1: | 2351 WEST 12 MILE ROAD | ||||||||
| Address2: | |||||||||
| City: | BERKLEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485444004 | ||||||||
| FaxNumber: | 2485444013 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2007 | ||||||||
| LastUpdateDate: | 09/17/2014 | ||||||||
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| AuthorizedOfficialLastName: | CLAYTON | ||||||||
| AuthorizedOfficialFirstName: | JAIMIE | ||||||||
| AuthorizedOfficialMiddleName: | PEARL | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2488587766 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OAKLAND FAMILY SERVICES | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 630317 | MI | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1883825 | 05 | MI | MEDICAID |