Basic Information
| Provider Information | |||||||||
| NPI: | 1679083372 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COPE PERSONAL DEVELOPMENT CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30016 HANOVER BLVD | ||||||||
| Address2: | |||||||||
| City: | WESTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481865125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489915779 | ||||||||
| FaxNumber: | 8883186010 | ||||||||
| Practice Location | |||||||||
| Address1: | 26711 WOODWARD AVE STE LL2 | ||||||||
| Address2: | |||||||||
| City: | HUNTINGTON WOODS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480701370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8559481661 | ||||||||
| FaxNumber: | 8883186010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2017 | ||||||||
| LastUpdateDate: | 10/09/2018 | ||||||||
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| AuthorizedOfficialLastName: | PARKMAN | ||||||||
| AuthorizedOfficialFirstName: | TINA | ||||||||
| AuthorizedOfficialMiddleName: | LARAYNE | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2489915779 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 6401003666 | MI | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1548462591 | 05 | MI | MEDICAID | 1184926446 | 05 | MI | MEDICAID | 1477876019 | 05 | MI | MEDICAID | 1851752596 | 05 | MI | MEDICAID |