Basic Information
| Provider Information | |||||||||
| NPI: | 1447357140 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HERON RIDGE ASSOCIATES PLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2550 S TELEGRAPH RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483020909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483220003 | ||||||||
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| Practice Location | |||||||||
| Address1: | 31000 TELEGRAPH RD STE 120 | ||||||||
| Address2: | |||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480254321 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485944991 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2006 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| AuthorizedOfficialLastName: | JOHNSEN | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2482448644 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801021651 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 10605 | 01 | MI | BLUE CROSS BLUE SHIELD MI | OTHER | 463240 | 01 | MI | VALUE OPTIONS | OTHER |