Basic Information
| Provider Information | |||||||||
| NPI: | 1568683761 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTER SEALS - MICHIGAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22150 W 9 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480336007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483726800 | ||||||||
| FaxNumber: | 2483576090 | ||||||||
| Practice Location | |||||||||
| Address1: | 22150 W 9 MILE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480336007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483726800 | ||||||||
| FaxNumber: | 2483576090 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2007 | ||||||||
| LastUpdateDate: | 11/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | SELLERS | ||||||||
| AuthorizedOfficialFirstName: | KERRI | ||||||||
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| AuthorizedOfficialTitleorPosition: | SITE MANGAGE | ||||||||
| AuthorizedOfficialTelephone: | 2483726800 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801088483 | MI | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1003028226 | 05 | MI | MEDICAID |