Basic Information
Provider Information | |||||||||
NPI: | 1811061948 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DETROIT INSTITUTE FOR CHILDREN | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2075 E WEST MAPLE RD STE B203 | ||||||||
Address2: |   | ||||||||
City: | COMMERCE TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 483903816 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2489184275 | ||||||||
FaxNumber: | 2486243332 | ||||||||
Practice Location | |||||||||
Address1: | 2075 E WEST MAPLE RD | ||||||||
Address2: |   | ||||||||
City: | COMMERCE TOWNSHIP | ||||||||
State: | MI | ||||||||
PostalCode: | 483903816 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2489184275 | ||||||||
FaxNumber: | 2486243332 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/20/2006 | ||||||||
LastUpdateDate: | 03/28/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BRINKERHOFF | ||||||||
AuthorizedOfficialFirstName: | ROXANNE | ||||||||
AuthorizedOfficialMiddleName: | L | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
AuthorizedOfficialTelephone: | 2489184275 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X |   |   | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.