Provider Demographics
NPI:1083858104
Name:OAKWOOD AMBULATORY, LLC
Entity Type:Organization
Organization Name:OAKWOOD AMBULATORY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR. DIRECTOR BEAUMONT SHARED SVCS
Authorized Official - Prefix:
Authorized Official - First Name:LESLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLBRANDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:947-522-1911
Mailing Address - Street 1:26901 BEAUMONT BOULEVARD
Mailing Address - Street 2:STE. 3D
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-3849
Mailing Address - Country:US
Mailing Address - Phone:947-522-1857
Mailing Address - Fax:
Practice Address - Street 1:2001 S MERRIMAN RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-5539
Practice Address - Country:US
Practice Address - Phone:734-727-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-21
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301006461103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N84060Medicare PIN