Basic Information
| Provider Information | |||||||||
| NPI: | 1124438320 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOUR CORNERS | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 15798 LIVERNOIS AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484958985 | ||||||||
| FaxNumber: | 2487197595 | ||||||||
| Practice Location | |||||||||
| Address1: | 15798 LIVERNOIS AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484958985 | ||||||||
| FaxNumber: | 2487197595 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2014 | ||||||||
| LastUpdateDate: | 04/28/2014 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CARTER | ||||||||
| AuthorizedOfficialFirstName: | KARICIA | ||||||||
| AuthorizedOfficialMiddleName: | REGENE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2484958985 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.