Basic Information
| Provider Information | |||||||||
| NPI: | 1699332007 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROBINSON | ||||||||
| FirstName: | KADERRICK | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 35755 N GRANDVIEW CT | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483352414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135759754 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2200 GENOA BUSINESS PARK DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | BRIGHTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481145328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104947180 | ||||||||
| FaxNumber: | 8102151334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2019 | ||||||||
| LastUpdateDate: | 12/07/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | 6801104464 | MI | N | Other Service Providers | Case Manager/Care Coordinator | 1041C0700X | 6801104464 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.