Basic Information
| Provider Information | |||||||||
| NPI: | 1083016356 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ELMHURST | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 PITKIN ST | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482033737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138651500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 245 PITKIN ST | ||||||||
| Address2: | |||||||||
| City: | HIGHLAND PARK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482033737 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138651500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2014 | ||||||||
| LastUpdateDate: | 09/18/2014 | ||||||||
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| AuthorizedOfficialLastName: | LIETZAU | ||||||||
| AuthorizedOfficialFirstName: | ASHLEY | ||||||||
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| AuthorizedOfficialTitleorPosition: | COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 3138651500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | 0822820 | MI | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
ID Information
| ID | Type | State | Issuer | Description | 0822820 | 01 | MI | COUNSELOR | OTHER |