Provider Demographics
NPI:1376968461
Name:EASTER SEALS
Entity Type:Organization
Organization Name:EASTER SEALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH CLINICIAN
Authorized Official - Prefix:
Authorized Official - First Name:SHAYLA
Authorized Official - Middle Name:
Authorized Official - Last Name:GLASS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-763-2399
Mailing Address - Street 1:24445 NORTHWESTERN HWY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-6501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:24445 NORTHWESTERN HWY
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-6501
Practice Address - Country:US
Practice Address - Phone:248-483-7804
Practice Address - Fax:248-483-7868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-26
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301015758251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health