Basic Information
| Provider Information | |||||||||
| NPI: | 1952510182 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HENRY FORD HEALTH SYSTEM MAPLEGROVE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6773 W MAPLE RD | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483223013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486616100 | ||||||||
| FaxNumber: | 2487883177 | ||||||||
| Practice Location | |||||||||
| Address1: | 6773 W MAPLE RD | ||||||||
| Address2: | |||||||||
| City: | WEST BLOOMFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483223013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486616100 | ||||||||
| FaxNumber: | 2487883177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | SEKULICH | ||||||||
| AuthorizedOfficialFirstName: | ANNA | ||||||||
| AuthorizedOfficialMiddleName: | CATHERINE | ||||||||
| AuthorizedOfficialTitleorPosition: | BEHAVIORAL HEALTH THERAPIST | ||||||||
| AuthorizedOfficialTelephone: | 2487883018 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | MSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0405X | 6801086544 | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Substance Use Disorder |
No ID Information.