Basic Information
| Provider Information | |||||||||
| NPI: | 1316181290 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KIM DEMBROSKY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1270 DORIS RD | ||||||||
| Address2: | |||||||||
| City: | AUBURN HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483262617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482768000 | ||||||||
| FaxNumber: | 2482769280 | ||||||||
| Practice Location | |||||||||
| Address1: | 1270 DORIS RD | ||||||||
| Address2: | |||||||||
| City: | AUBURN HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483262617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482768000 | ||||||||
| FaxNumber: | 2482769280 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2009 | ||||||||
| LastUpdateDate: | 04/30/2009 | ||||||||
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| AuthorizedOfficialLastName: | DEMBROSKY | ||||||||
| AuthorizedOfficialFirstName: | KIM | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | SUPPORTS COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2482768093 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | LBSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 6802080970 | MI | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 104100000X | 05 | MI | MEDICAID |