Provider Demographics
NPI:1669466611
Name:MOTHER'S FRIEND MATERNAL/INFANT SUPPORT SERVICES
Entity Type:Organization
Organization Name:MOTHER'S FRIEND MATERNAL/INFANT SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DASHUNA
Authorized Official - Middle Name:RELIEU
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:248-559-5722
Mailing Address - Street 1:14401 GREENVIEW RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48223-2913
Mailing Address - Country:US
Mailing Address - Phone:248-559-5722
Mailing Address - Fax:248-559-5622
Practice Address - Street 1:16250 NORTHLAND DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-5208
Practice Address - Country:US
Practice Address - Phone:248-559-5722
Practice Address - Fax:248-559-5622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4556235Medicaid