Provider Demographics
NPI:1720360456
Name:TESTING AND TREATMENT SERVICES OF MICHIGAN
Entity Type:Organization
Organization Name:TESTING AND TREATMENT SERVICES OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LEAD THERAPIST/ OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MELVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:HOBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MSW, CSW
Authorized Official - Phone:248-561-0003
Mailing Address - Street 1:1800 GRINDLEY PARK ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2553
Mailing Address - Country:US
Mailing Address - Phone:313-277-1166
Mailing Address - Fax:
Practice Address - Street 1:1800 GRINDLEY PARK ST
Practice Address - Street 2:SUITE 1
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-2553
Practice Address - Country:US
Practice Address - Phone:313-277-1166
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-20
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010111116302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1497812523Medicaid
MI0P25740Medicare PIN