Provider Demographics
NPI:1073062725
Name:MISSIONARY SERVANTS OF DIVINE PROVIDENCE
Entity Type:Organization
Organization Name:MISSIONARY SERVANTS OF DIVINE PROVIDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/ DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUSTINA
Authorized Official - Middle Name:E
Authorized Official - Last Name:UDEAGHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-560-5014
Mailing Address - Street 1:4101 MOORE ST
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-3017
Mailing Address - Country:US
Mailing Address - Phone:734-560-5014
Mailing Address - Fax:313-633-9510
Practice Address - Street 1:26629 HOPKINS ST
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-3111
Practice Address - Country:US
Practice Address - Phone:734-560-5014
Practice Address - Fax:313-633-9510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-22
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010846131041C0700X, 251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1578772240Medicaid