Provider Demographics
NPI:1568998425
Name:THE SALVATION ARMY HABOR LIGHT ONWARD
Entity Type:Organization
Organization Name:THE SALVATION ARMY HABOR LIGHT ONWARD
Other - Org Name:ONWARD
Other - Org Type:Other Name
Authorized Official - Title/Position:SITE ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELINDA
Authorized Official - Middle Name:A
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:MSW
Authorized Official - Phone:586-954-1838
Mailing Address - Street 1:42590 STEPNITZ DR
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48036-3161
Mailing Address - Country:US
Mailing Address - Phone:586-954-1838
Mailing Address - Fax:586-954-9856
Practice Address - Street 1:24140 MOUND RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-5322
Practice Address - Country:US
Practice Address - Phone:586-954-1838
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THE SALVATION ARMY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA0500484251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI192115Medicaid