Provider Demographics
NPI:1083960009
Name:THE MOM AND BABY PROGRAM
Entity Type:Organization
Organization Name:THE MOM AND BABY PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR MIHP COORDINATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LORETTA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN
Authorized Official - Phone:248-838-9665
Mailing Address - Street 1:129 E UNIVERSITY DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2046
Mailing Address - Country:US
Mailing Address - Phone:248-838-9665
Mailing Address - Fax:248-659-5207
Practice Address - Street 1:129 E UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MI
Practice Address - Zip Code:48307-2046
Practice Address - Country:US
Practice Address - Phone:248-838-9665
Practice Address - Fax:248-659-5207
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704160228251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management