Provider Demographics
NPI:1376257303
Name:PRODIGAL JOURNEY, LLC
Entity Type:Organization
Organization Name:PRODIGAL JOURNEY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TODD
Authorized Official - Middle Name:
Authorized Official - Last Name:LOSIE
Authorized Official - Suffix:
Authorized Official - Credentials:MATL, MS, LMSW-C
Authorized Official - Phone:248-956-1157
Mailing Address - Street 1:33234 KINGSLANE CT APT 7
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48336-4054
Mailing Address - Country:US
Mailing Address - Phone:313-702-3136
Mailing Address - Fax:
Practice Address - Street 1:33234 KINGSLANE CT APT 7
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48336-4054
Practice Address - Country:US
Practice Address - Phone:313-702-3136
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-13
Last Update Date:2023-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty