Basic Information
| Provider Information | |||||||||
| NPI: | 1497086664 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 62 W 7 MILE RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482031967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138936172 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 62 W 7 MILE RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482031967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138936172 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2010 | ||||||||
| LastUpdateDate: | 01/27/2010 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SARAFA | ||||||||
| AuthorizedOfficialFirstName: | CARMEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DEPUTY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 3138936172 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MA,LPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 4704272539 | MI | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 3434247 | 05 | MI | MEDICAID |