Provider Demographics
NPI:1447779061
Name:MENTORS OF MICHIGAN INC.
Entity Type:Organization
Organization Name:MENTORS OF MICHIGAN INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DEVEREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-632-3534
Mailing Address - Street 1:3812 FINCH DR
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1667
Mailing Address - Country:US
Mailing Address - Phone:248-632-3534
Mailing Address - Fax:248-269-7167
Practice Address - Street 1:10140 CURTIS LN
Practice Address - Street 2:
Practice Address - City:WHITE LAKE
Practice Address - State:MI
Practice Address - Zip Code:48386-3813
Practice Address - Country:US
Practice Address - Phone:248-360-1714
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS630273674253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency