Provider Demographics
NPI:1154472710
Name:BOYS & GIRLS REPUBLIC
Entity Type:Organization
Organization Name:BOYS & GIRLS REPUBLIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MARYJANE
Authorized Official - Middle Name:
Authorized Official - Last Name:PECK
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-476-9550
Mailing Address - Street 1:28000 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-3812
Mailing Address - Country:US
Mailing Address - Phone:248-476-9550
Mailing Address - Fax:248-473-6332
Practice Address - Street 1:28000 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-3812
Practice Address - Country:US
Practice Address - Phone:248-476-9550
Practice Address - Fax:248-473-6332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC1630200987322D00000X
MI251V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Not Answered251V00000XAgenciesVoluntary or Charitable