Provider Demographics
NPI:1316181290
Name:KIM DEMBROSKY
Entity Type:Organization
Organization Name:KIM DEMBROSKY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPPORTS COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEMBROSKY
Authorized Official - Suffix:
Authorized Official - Credentials:LBSW
Authorized Official - Phone:248-276-8093
Mailing Address - Street 1:1270 DORIS RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-2617
Mailing Address - Country:US
Mailing Address - Phone:248-276-8000
Mailing Address - Fax:248-276-9280
Practice Address - Street 1:1270 DORIS RD
Practice Address - Street 2:
Practice Address - City:AUBURN HILLS
Practice Address - State:MI
Practice Address - Zip Code:48326-2617
Practice Address - Country:US
Practice Address - Phone:248-276-8000
Practice Address - Fax:248-276-9280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-23
Last Update Date:2009-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802080970251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104100000XMedicaid