Provider Demographics
NPI:1568776086
Name:EXEC-U-TECH BEHAVIORAL THERAPY
Entity Type:Organization
Organization Name:EXEC-U-TECH BEHAVIORAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AURELIA
Authorized Official - Middle Name:LAFAYE
Authorized Official - Last Name:KENT
Authorized Official - Suffix:
Authorized Official - Credentials:LLMSW
Authorized Official - Phone:313-475-0283
Mailing Address - Street 1:1804 CAMPAU FARMS CIR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-5164
Mailing Address - Country:US
Mailing Address - Phone:313-475-0283
Mailing Address - Fax:
Practice Address - Street 1:505 BEECHWOOD ST
Practice Address - Street 2:
Practice Address - City:RIVER ROUGE
Practice Address - State:MI
Practice Address - Zip Code:48218-1041
Practice Address - Country:US
Practice Address - Phone:313-386-2288
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-27
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801091303251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health