Basic Information
| Provider Information | |||||||||
| NPI: | 1427336411 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST GUIDANCE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 CONNER AVENUE | ||||||||
| Address2: | BLDG A | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133081400 | ||||||||
| FaxNumber: | 3133081600 | ||||||||
| Practice Location | |||||||||
| Address1: | 12800 E WARREN AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482152061 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138248000 | ||||||||
| FaxNumber: | 3138245589 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2011 | ||||||||
| LastUpdateDate: | 07/26/2011 | ||||||||
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| AuthorizedOfficialLastName: | NEDERLANDER | ||||||||
| AuthorizedOfficialFirstName: | SUE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 3138245642 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | N | Agencies | Community/Behavioral Health | 2084P0804X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 21-3119549 | 05 | MI | MEDICAID |