Provider Demographics
NPI:1790024651
Name:RAGLAND, MICHAEL CORNELL
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:CORNELL
Last Name:RAGLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1852 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-1006
Mailing Address - Country:US
Mailing Address - Phone:313-894-8444
Mailing Address - Fax:313-894-5542
Practice Address - Street 1:1852 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1006
Practice Address - Country:US
Practice Address - Phone:313-894-8444
Practice Address - Fax:313-894-5542
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-12
Last Update Date:2013-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI381917278Medicaid