Basic Information
| Provider Information | |||||||||
| NPI: | 1114114733 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | OAKLAND FAMILY SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 114 ORCHARD LAKE RD | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483412244 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488587766 | ||||||||
| FaxNumber: | 2488587201 | ||||||||
| Practice Location | |||||||||
| Address1: | 23332 ORCHARD LAKE RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483363280 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484731290 | ||||||||
| FaxNumber: | 2484731293 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2007 | ||||||||
| LastUpdateDate: | 09/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | EARL | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 2488587766 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | OAKLAND FAMILY SERVICES | ||||||||
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| AuthorizedOfficialCredential: | LMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 630845 | MI | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 1883825 | 05 | MI | MEDICAID |