Provider Demographics
NPI:1477671170
Name:NATIONAL COUNCIL ON ALCOHOLISM DRUG DEPENDENCE
Entity Type:Organization
Organization Name:NATIONAL COUNCIL ON ALCOHOLISM DRUG DEPENDENCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:CEO
Authorized Official - Phone:313-369-5400
Mailing Address - Street 1:16647 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2848
Mailing Address - Country:US
Mailing Address - Phone:313-341-9891
Mailing Address - Fax:313-861-0413
Practice Address - Street 1:16647 WYOMING ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2848
Practice Address - Country:US
Practice Address - Phone:313-341-9891
Practice Address - Fax:313-861-0413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI199150Medicaid