Provider Demographics
NPI:1043562036
Name:EASTER SEALS MICHIGAN
Entity Type:Organization
Organization Name:EASTER SEALS MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED PSYCHIATRIST NURSE
Authorized Official - Prefix:
Authorized Official - First Name:MERRY
Authorized Official - Middle Name:RUTH
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:248-372-6896
Mailing Address - Street 1:21395 OXFORD AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-6150
Mailing Address - Country:US
Mailing Address - Phone:248-473-1477
Mailing Address - Fax:248-893-7842
Practice Address - Street 1:22170 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-6007
Practice Address - Country:US
Practice Address - Phone:248-372-6896
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-15
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704068664163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty