Basic Information
| Provider Information | |||||||||
| NPI: | 1104249374 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMON GROUND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 34971 AQUARIUS DR | ||||||||
| Address2: | |||||||||
| City: | STERLING HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483105633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485545818 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1410 TELEGRAPH ROAD | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48332 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483413780 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2014 | ||||||||
| LastUpdateDate: | 01/24/2014 | ||||||||
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| AuthorizedOfficialLastName: | PRELLBERG | ||||||||
| AuthorizedOfficialFirstName: | EMILY | ||||||||
| AuthorizedOfficialMiddleName: | SUZANNE | ||||||||
| AuthorizedOfficialTitleorPosition: | REGISTERED NURSE | ||||||||
| AuthorizedOfficialTelephone: | 2485545818 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 4704298086 | MI | Y | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |
ID Information
| ID | Type | State | Issuer | Description | 2222222 | 05 | MI | MEDICAID | 1111111 | 05 | MI | MEDICAID |