Provider Demographics
NPI:1578582045
Name:WAYNE COUNTY REGIONAL EDUCATIONAL SERVICE AGENCY
Entity Type:Organization
Organization Name:WAYNE COUNTY REGIONAL EDUCATIONAL SERVICE AGENCY
Other - Org Name:WAYNE RESA
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, MEDICAID REIMB
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:CUMMINS
Authorized Official - Last Name:MERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-334-1820
Mailing Address - Street 1:33500 VAN BORN ROAD
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184
Mailing Address - Country:US
Mailing Address - Phone:734-334-1820
Mailing Address - Fax:734-334-1824
Practice Address - Street 1:33500 VAN BORN RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2474
Practice Address - Country:US
Practice Address - Phone:734-334-1820
Practice Address - Fax:734-334-1824
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2912959Medicaid