Provider Demographics
NPI:1609300490
Name:TRANSFORMATION CENTER FOR VICTIMS OF ABUSE
Entity Type:Organization
Organization Name:TRANSFORMATION CENTER FOR VICTIMS OF ABUSE
Other - Org Name:TRANSFORMATION CENTER
Other - Org Type:Other Name
Authorized Official - Title/Position:FOUNDER/PRESIDENT/CEO
Authorized Official - Prefix:MS
Authorized Official - First Name:DELLA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HAMBLIN-CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-718-7456
Mailing Address - Street 1:23411 JEFFERSON AVE
Mailing Address - Street 2:107
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1949
Mailing Address - Country:US
Mailing Address - Phone:586-585-1789
Mailing Address - Fax:586-585-1332
Practice Address - Street 1:23411 JEFFERSON AVE
Practice Address - Street 2:107
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1949
Practice Address - Country:US
Practice Address - Phone:586-585-1789
Practice Address - Fax:586-585-1332
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC-01284251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health