Provider Demographics
NPI:1376661959
Name:BOBB-SEMPLE, CONRAD MICHAEL (FAODP)
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:MICHAEL
Last Name:BOBB-SEMPLE
Suffix:
Gender:M
Credentials:FAODP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24081 JEROME ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-2179
Mailing Address - Country:US
Mailing Address - Phone:313-717-8157
Mailing Address - Fax:
Practice Address - Street 1:13220 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3610
Practice Address - Country:US
Practice Address - Phone:313-852-1637
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1740313238OtherCHRISTIAN GUIDANCE CENTER
MI3022440Medicaid