Provider Demographics
NPI:1568040798
Name:YOUR GOODVILLAGE COLLECTIVE
Entity Type:Organization
Organization Name:YOUR GOODVILLAGE COLLECTIVE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDING EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANJANETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT HATTER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:313-510-7003
Mailing Address - Street 1:12811 HEMINGWAY
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-4606
Mailing Address - Country:US
Mailing Address - Phone:313-510-7003
Mailing Address - Fax:
Practice Address - Street 1:12811 HEMINGWAY
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-4606
Practice Address - Country:US
Practice Address - Phone:888-357-2366
Practice Address - Fax:888-357-2366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-30
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No251B00000XAgenciesCase Management
No251S00000XAgenciesCommunity/Behavioral Health