Basic Information
| Provider Information | |||||||||
| NPI: | 1528145844 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE CHILDREN'S CENTER OF WAYNE CO., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79 W ALEXANDRINE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138315535 | ||||||||
| FaxNumber: | 3134472623 | ||||||||
| Practice Location | |||||||||
| Address1: | 79 W ALEXANDRINE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482012015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138315535 | ||||||||
| FaxNumber: | 3134472623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 05/23/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LEID | ||||||||
| AuthorizedOfficialFirstName: | TIFFANY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR - RCM & CLIENT RELATIONS | ||||||||
| AuthorizedOfficialTelephone: | 3132620951 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 253J00000X | N | Agencies | Foster Care Agency | 252Y00000X | N | Agencies | Early Intervention Provider Agency | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 653610 | 01 | MI | CONSUMERLINK | OTHER | 000100 | 01 | MI | CARELINK | OTHER | 118605 | 01 | MI | VALUE OPTIONS | OTHER | 1528145844 | 01 | MI | BCN | OTHER | 21 3119549 | 05 | MI | MEDICAID | 750910564 | 01 | MI | BCBS | OTHER |