Provider Demographics
NPI:1508400573
Name:QUIET AVENUE LLC
Entity Type:Organization
Organization Name:QUIET AVENUE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW, CAADC
Authorized Official - Phone:313-992-9002
Mailing Address - Street 1:16835 WESTMORELAND RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-4028
Mailing Address - Country:US
Mailing Address - Phone:313-532-3615
Mailing Address - Fax:313-532-3615
Practice Address - Street 1:5555 CONNER ST STE 3096
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3817
Practice Address - Country:US
Practice Address - Phone:313-992-9002
Practice Address - Fax:313-532-3615
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-03
Last Update Date:2019-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty