Provider Demographics
NPI:1710102249
Name:GRATIOT CLINIC
Entity Type:Organization
Organization Name:GRATIOT CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC SUPERVISOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:PERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-887-6760
Mailing Address - Street 1:3506 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-1830
Mailing Address - Country:US
Mailing Address - Phone:313-887-6761
Mailing Address - Fax:313-852-4847
Practice Address - Street 1:3506 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-1830
Practice Address - Country:US
Practice Address - Phone:313-887-6761
Practice Address - Fax:313-852-4847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI820522101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI10142OtherSTATE LICENSE