Basic Information
| Provider Information | |||||||||
| NPI: | 1306383252 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TEAM MENTAL HEALTH SERVICES INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | TEAM WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 921 HOWARD ST | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481242210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132743700 | ||||||||
| FaxNumber: | 3135515365 | ||||||||
| Practice Location | |||||||||
| Address1: | 3646 MOUNT ELLIOTT ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482072311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3136262400 | ||||||||
| FaxNumber: | 3139214125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2017 | ||||||||
| LastUpdateDate: | 01/30/2017 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | POLLICELLA | ||||||||
| AuthorizedOfficialFirstName: | ANTONIO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF EXECUTIVE OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3132743700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | Dental Public Health | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.