Provider Demographics
NPI:1477821502
Name:EASTER SEALS
Entity Type:Organization
Organization Name:EASTER SEALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EVIDENCE BASED PRACTICE COORDINATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:LUCIDO
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, NCC, CAADC
Authorized Official - Phone:586-855-1182
Mailing Address - Street 1:22170 W 9 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48033-6007
Mailing Address - Country:US
Mailing Address - Phone:248-372-6800
Mailing Address - Fax:
Practice Address - Street 1:22170 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-6007
Practice Address - Country:US
Practice Address - Phone:248-372-6800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-03
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011529251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health