Provider Demographics
NPI:1003180902
Name:CHERRY STREAT HEALTH SERVICES
Entity Type:Organization
Organization Name:CHERRY STREAT HEALTH SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:AVERY
Authorized Official - Middle Name:E
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:JR
Authorized Official - Credentials:MA, LPC, CAAC, ICAAD
Authorized Official - Phone:313-822-4060
Mailing Address - Street 1:11105 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-3317
Mailing Address - Country:US
Mailing Address - Phone:313-822-4060
Mailing Address - Fax:313-822-1130
Practice Address - Street 1:11105 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-3317
Practice Address - Country:US
Practice Address - Phone:313-822-4060
Practice Address - Fax:313-822-1130
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-24
Last Update Date:2012-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI822051324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility