Basic Information
| Provider Information | |||||||||
| NPI: | 1861747578 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SALVATION ARMY HARBOR LIGHT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3250 N MONROE ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481629297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343843402 | ||||||||
| FaxNumber: | 7343843420 | ||||||||
| Practice Location | |||||||||
| Address1: | 3250 N MONROE ST | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481629297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343843402 | ||||||||
| FaxNumber: | 7343843420 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2012 | ||||||||
| LastUpdateDate: | 07/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | TURSAK | ||||||||
| AuthorizedOfficialFirstName: | MARGORIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CLINICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 7343843402 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MISS | ||||||||
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| AuthorizedOfficialCredential: | LPC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X | L2238243 | MI | Y | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |
No ID Information.