Provider Demographics
NPI:1770821795
Name:ST JOHN PROVIDENCE HEALTH SYSTEMS
Entity Type:Organization
Organization Name:ST JOHN PROVIDENCE HEALTH SYSTEMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:LLPC
Authorized Official - Phone:313-368-4267
Mailing Address - Street 1:1150 E LANTZ ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-1376
Mailing Address - Country:US
Mailing Address - Phone:313-368-4267
Mailing Address - Fax:313-368-4470
Practice Address - Street 1:1150 LANTZ ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203
Practice Address - Country:US
Practice Address - Phone:313-368-4267
Practice Address - Fax:313-368-4470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health