Provider Demographics
NPI:1164721890
Name:EASTER SEALS MICHIGAN
Entity Type:Organization
Organization Name:EASTER SEALS MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MENTAL HEALTH CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:D
Authorized Official - Last Name:POWELL MEDLOCK
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-475-6300
Mailing Address - Street 1:2387 E WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-1955
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2387 E WALTON BLVD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-1955
Practice Address - Country:US
Practice Address - Phone:248-475-6300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-21
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1041C0700X251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health