Basic Information
| Provider Information | |||||||||
| NPI: | 1710286836 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST GUIDANCE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2900 CONNER ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48215 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2900 CONNER ST | ||||||||
| Address2: | STE A | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3133081400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2011 | ||||||||
| LastUpdateDate: | 03/16/2011 | ||||||||
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| AuthorizedOfficialLastName: | MCRILL | ||||||||
| AuthorizedOfficialFirstName: | SHERRY | ||||||||
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| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3133081400 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LLP | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | 6401011079 | MI | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 6401011079 | 05 | MI | MEDICAID |