Provider Demographics
NPI:1417251943
Name:DREAM PROFESSIONAL SERVICES, LLC
Entity Type:Organization
Organization Name:DREAM PROFESSIONAL SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MICHELLE
Authorized Official - Last Name:FOUCHE BRAZZLE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:248-932-0290
Mailing Address - Street 1:5640 W MAPLE RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3716
Mailing Address - Country:US
Mailing Address - Phone:248-932-0290
Mailing Address - Fax:248-932-0358
Practice Address - Street 1:5640 W MAPLE RD
Practice Address - Street 2:SUITE 310
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3716
Practice Address - Country:US
Practice Address - Phone:248-932-0290
Practice Address - Fax:248-932-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-23
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052026261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)