Provider Demographics
NPI:1790873347
Name:TRANSITIONAL LIFESTYLES COMMUNITY, INC
Entity Type:Organization
Organization Name:TRANSITIONAL LIFESTYLES COMMUNITY, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW, ACSW,CAAC,QSAP
Authorized Official - Phone:810-908-7320
Mailing Address - Street 1:PO BOX 310365
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48531-0365
Mailing Address - Country:US
Mailing Address - Phone:810-908-7320
Mailing Address - Fax:
Practice Address - Street 1:115 W 5TH AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-2472
Practice Address - Country:US
Practice Address - Phone:810-908-7320
Practice Address - Fax:810-877-6453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010827091041C0700X
MI250346324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI2052Medicare UPIN