Basic Information
| Provider Information | |||||||||
| NPI: | 1093114266 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANAUKEN | ||||||||
| FirstName: | CHARLES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11000 W MCNICHOLS RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482212357 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 11000 W MCNICHOLS RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482212357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133404442 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2014 | ||||||||
| LastUpdateDate: | 08/14/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TM1800X | Y | Behavioral Health & Social Service Providers | Psychologist | Mental Retardation & Developmental Disabilities |
ID Information
| ID | Type | State | Issuer | Description | 320121988 | 05 | MI | MEDICAID |