Provider Demographics
NPI:1588855100
Name:TEAM MENTAL HEALTH SERVICES INC.
Entity Type:Organization
Organization Name:TEAM MENTAL HEALTH SERVICES INC.
Other - Org Name:TEAM WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANTONIO
Authorized Official - Middle Name:
Authorized Official - Last Name:POLLICELLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-274-3700
Mailing Address - Street 1:290 TOWN CENTER DR STE 400
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-2765
Mailing Address - Country:US
Mailing Address - Phone:313-274-3700
Mailing Address - Fax:
Practice Address - Street 1:2925 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-4825
Practice Address - Country:US
Practice Address - Phone:313-396-5300
Practice Address - Fax:313-396-5353
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-08
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4696337Medicaid