Basic Information
Provider Information | |||||||||
NPI: | 1629235924 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTER SEALS - MICHIGAN, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | CENTRO LATINO | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2387 E WALTON BLVD | ||||||||
Address2: |   | ||||||||
City: | AUBURN HILLS | ||||||||
State: | MI | ||||||||
PostalCode: | 483261955 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2484756400 | ||||||||
FaxNumber: | 2484756402 | ||||||||
Practice Location | |||||||||
Address1: | 269 SUMMIT DR | ||||||||
Address2: |   | ||||||||
City: | WATERFORD | ||||||||
State: | MI | ||||||||
PostalCode: | 483283364 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2486811940 | ||||||||
FaxNumber: | 2487063455 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/22/2008 | ||||||||
LastUpdateDate: | 08/26/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | WIRTH | ||||||||
AuthorizedOfficialFirstName: | BRENT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2484756400 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | EASTER SEALS - MICHIGAN, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/26/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X |   |   | Y |   | Agencies | Community/Behavioral Health |   |
No ID Information.