Provider Demographics
NPI:1477762474
Name:MICHIGAN INSTITUTE FOR PREVENTION INTERVENTION
Entity Type:Organization
Organization Name:MICHIGAN INSTITUTE FOR PREVENTION INTERVENTION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-579-9468
Mailing Address - Street 1:18530 MACK AVE
Mailing Address - Street 2:101
Mailing Address - City:GROSSE POINTE FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-3254
Mailing Address - Country:US
Mailing Address - Phone:313-579-9468
Mailing Address - Fax:
Practice Address - Street 1:18530 MACK AVE
Practice Address - Street 2:101
Practice Address - City:GROSSE POINTE FARMS
Practice Address - State:MI
Practice Address - Zip Code:48236-3254
Practice Address - Country:US
Practice Address - Phone:313-579-9468
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005272251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health