Basic Information
| Provider Information | |||||||||
| NPI: | 1629476379 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST GUIDANCE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 661 COVINGTON DR APT B6 | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482033834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137843336 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12800 WARREN | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138248000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/11/2014 | ||||||||
| LastUpdateDate: | 12/11/2014 | ||||||||
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| AuthorizedOfficialLastName: | PRICE | ||||||||
| AuthorizedOfficialFirstName: | TONY | ||||||||
| AuthorizedOfficialMiddleName: | LAMONT | ||||||||
| AuthorizedOfficialTitleorPosition: | ACT ADVOCATE | ||||||||
| AuthorizedOfficialTelephone: | 3137843336 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | YES | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 680208715 | MI | Y | Agencies | Community/Behavioral Health |
No ID Information.