Basic Information
| Provider Information | |||||||||
| NPI: | 1184061426 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOYSVILLE OF MICHIGAN, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | HOLY CROSS SERVICES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8759 CLINTON MACON RD | ||||||||
| Address2: | |||||||||
| City: | CLINTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492369572 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5174237556 | ||||||||
| FaxNumber: | 5174235442 | ||||||||
| Practice Location | |||||||||
| Address1: | 35 S JOHNSON ST | ||||||||
| Address2: | SUITE 3C | ||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483411658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483337222 | ||||||||
| FaxNumber: | 2483337254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2013 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BAUDOUX | ||||||||
| AuthorizedOfficialFirstName: | PAULINE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL OFFICE COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 9895963558 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | SA0631363 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.