Basic Information
| Provider Information | |||||||||
| NPI: | 1043562036 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21395 OXFORD AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483366150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484731477 | ||||||||
| FaxNumber: | 2488937842 | ||||||||
| Practice Location | |||||||||
| Address1: | 22170 W 9 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480336007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483726896 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2012 | ||||||||
| LastUpdateDate: | 10/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | MITCHELL | ||||||||
| AuthorizedOfficialFirstName: | MERRY | ||||||||
| AuthorizedOfficialMiddleName: | RUTH | ||||||||
| AuthorizedOfficialTitleorPosition: | REGISTERED PSYCHIATRIST NURSE | ||||||||
| AuthorizedOfficialTelephone: | 2483726896 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | R.N. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 4704068664 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Nursing Service Providers | Registered Nurse |
No ID Information.