Provider Demographics
NPI:1568739159
Name:CREATING A HEALTHY COMMUNITY
Entity Type:Organization
Organization Name:CREATING A HEALTHY COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:VIRDELL
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW,CCS,CAADC,SAP,
Authorized Official - Phone:313-588-0101
Mailing Address - Street 1:5077 AUDUBON RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2658
Mailing Address - Country:US
Mailing Address - Phone:313-588-0101
Mailing Address - Fax:
Practice Address - Street 1:5575 CONNER ST
Practice Address - Street 2:SUITE 204
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-6400
Practice Address - Country:US
Practice Address - Phone:313-588-0101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-26
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI822496251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI822496OtherMICHIGAN SUBSTANCE ABUSE LICENSE