Basic Information
| Provider Information | |||||||||
| NPI: | 1770658239 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DETROIT INSTITUTE FOR CHILDREN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE ABILITIES CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5447 WOODWARD AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482024009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138321100 | ||||||||
| FaxNumber: | 3135784520 | ||||||||
| Practice Location | |||||||||
| Address1: | 2075 E WEST MAPLE RD | ||||||||
| Address2: | SUITE B-204 | ||||||||
| City: | COMMERCE TOWNSHIP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483903816 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2489260909 | ||||||||
| FaxNumber: | 3135784520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 04/04/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLEARY | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 3135784503 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DETROIT INSTITUTE FOR CHILDREN | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.