Basic Information
| Provider Information | |||||||||
| NPI: | 1992824809 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BOTSFORD CONTINUING CARE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BOTSFORD SENIOR ASSESSMENT AND TREATMENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 26901 BEAUMONT BLVD. | ||||||||
| Address2: | COMPLIANCE | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480334716 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9475221963 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 21440 ARCHWOOD CIR | ||||||||
| Address2: | BOTSFORD SENIOR ASSESSMENT AND TREATMENT CENTER | ||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483364127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484266951 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 10/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ODOM | ||||||||
| AuthorizedOfficialFirstName: | LEE | ||||||||
| AuthorizedOfficialMiddleName: | ANN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT SHARED SERVICES | ||||||||
| AuthorizedOfficialTelephone: | 9475223326 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | BOTSFORD CONTINUING CARE | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TA0700X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Adult Development & Aging | 101YM0800X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.