Basic Information
Provider Information | |||||||||
NPI: | 1477821502 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTER SEALS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 22170 W 9 MILE RD | ||||||||
Address2: |   | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480336007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483726800 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 22170 W 9 MILE RD | ||||||||
Address2: |   | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480336007 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483726800 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/03/2011 | ||||||||
LastUpdateDate: | 08/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LUCIDO | ||||||||
AuthorizedOfficialFirstName: | JENNIFER | ||||||||
AuthorizedOfficialMiddleName: | MARIE | ||||||||
AuthorizedOfficialTitleorPosition: | EVIDENCE BASED PRACTICE COORDINATOR | ||||||||
AuthorizedOfficialTelephone: | 5868551182 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MISS | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MA, LPC, NCC, CAADC | ||||||||
NPICertificationDate: | 08/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 6401011529 | MI | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.