Provider Demographics
NPI:1376526616
Name:EASTER SEALS - MICHIGAN, INC.
Entity Type:Organization
Organization Name:EASTER SEALS - MICHIGAN, INC.
Other - Org Name:ADMINISTRATIVE OFFICE
Other - Org Type:Other Name
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:WIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-475-6400
Mailing Address - Street 1:2399 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:248-475-6400
Mailing Address - Fax:248-475-6402
Practice Address - Street 1:2399 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:248-475-6400
Practice Address - Fax:248-475-6402
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-21
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251S00000XAgenciesCommunity/Behavioral HealthGroup - Single Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No251V00000XAgenciesVoluntary or Charitable
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N26360Medicare ID - Type Unspecified