Basic Information
Provider Information | |||||||||
NPI: | 1376730994 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | OAKLAND FAMILY SERVICES | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 114 ORCHARD LAKE ROAD | ||||||||
Address2: |   | ||||||||
City: | PONTIAC | ||||||||
State: | MI | ||||||||
PostalCode: | 48341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2488587766 | ||||||||
FaxNumber: | 2488587201 | ||||||||
Practice Location | |||||||||
Address1: | 2045 EAST WEST MAPLE ROAD | ||||||||
Address2: | SUITE D-407 | ||||||||
City: | WALLED LAKE | ||||||||
State: | MI | ||||||||
PostalCode: | 48390 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486243811 | ||||||||
FaxNumber: | 2486240368 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/27/2007 | ||||||||
LastUpdateDate: | 09/17/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CLAYTON | ||||||||
AuthorizedOfficialFirstName: | JAIMIE | ||||||||
AuthorizedOfficialMiddleName: | PEARL | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 2488587799 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | OAKLAND FAMILY SERVICES | ||||||||
AuthorizedOfficialNamePrefix: | MS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 630316 | MI | Y |   | Agencies | Community/Behavioral Health |   |
ID Information
ID | Type | State | Issuer | Description | 1883825 | 05 | MI |   | MEDICAID |