Provider Demographics
NPI:1386826949
Name:PEACE IN YOUNG LIFE CENTER, INC.
Entity Type:Organization
Organization Name:PEACE IN YOUNG LIFE CENTER, INC.
Other - Org Name:PEACE HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MARCHELLE
Authorized Official - Middle Name:MITZI
Authorized Official - Last Name:GAINES
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:313-220-9033
Mailing Address - Street 1:15471 CLOVERLAWN ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-1146
Mailing Address - Country:US
Mailing Address - Phone:706-263-2533
Mailing Address - Fax:
Practice Address - Street 1:15471 CLOVERLAWN ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-1146
Practice Address - Country:US
Practice Address - Phone:313-220-9033
Practice Address - Fax:313-345-4358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-05
Last Update Date:2013-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty