Basic Information
| Provider Information | |||||||||
| NPI: | 1548500804 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | ROSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 707 W MILWAUKEE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138332500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 707 W MILWAUKEE ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482022943 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138332500 | ||||||||
| FaxNumber: | 3132852430 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/25/2013 | ||||||||
| LastUpdateDate: | 03/18/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 6803075896 | MI | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 171M00000X | 6803075896 | MI | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 6803075896 | 01 | MI | CADA PLAN | OTHER |