Provider Demographics
NPI:1760936926
Name:DETROIT EAST
Entity Type:Organization
Organization Name:DETROIT EAST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:CICHON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-626-2321
Mailing Address - Street 1:8925 E JEFFERSON AVE
Mailing Address - Street 2:APT 14 SOUTH
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-4183
Mailing Address - Country:US
Mailing Address - Phone:313-384-8449
Mailing Address - Fax:
Practice Address - Street 1:8925 E JEFFERSON AVE
Practice Address - Street 2:APT 14 SOUTH
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-4183
Practice Address - Country:US
Practice Address - Phone:313-384-8449
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-05
Last Update Date:2016-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801015243251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health