Provider Demographics
NPI:1326242827
Name:MIDWEST JOURNEYS LLC
Entity Type:Organization
Organization Name:MIDWEST JOURNEYS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM AND CLINICAL DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ROXANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNTLEY-MATOS
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:734-474-0792
Mailing Address - Street 1:PO BOX 3193
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48106-3193
Mailing Address - Country:US
Mailing Address - Phone:734-829-0075
Mailing Address - Fax:
Practice Address - Street 1:2142A WASHTENAW RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1708
Practice Address - Country:US
Practice Address - Phone:734-829-0075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2007-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010787421041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty