Basic Information
| Provider Information | |||||||||
| NPI: | 1700888674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CALVERT | ||||||||
| FirstName: | QUENTIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | CSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25925 TELEGRAPH RD | ||||||||
| Address2: | 210 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480342518 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2487460342 | ||||||||
| FaxNumber: | 2487460308 | ||||||||
| Practice Location | |||||||||
| Address1: | 22255 GREENFIELD RD | ||||||||
| Address2: | 132 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480753710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488493301 | ||||||||
| FaxNumber: | 2488495378 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2005 | ||||||||
| LastUpdateDate: | 09/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 6801017944 | MI | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 5301002923 | 01 | MI | LLP | OTHER |