Basic Information
| Provider Information | |||||||||
| NPI: | 1356949390 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LIVONIA PUBLIC SCHOOLS SCHOOL DISTRICT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 MACK AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134489006 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8900 NEWBURGH RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481503425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7347442650 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2020 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| AuthorizedOfficialLastName: | GOODE | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
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| AuthorizedOfficialTitleorPosition: | WAYNE HEALTH VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 3134489006 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNIVERSITY PHYSICIAN GROUP | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School |
No ID Information.