Provider Demographics
NPI:1841204641
Name:THE ADULT PSYCHIATRIC CLINIC
Entity Type:Organization
Organization Name:THE ADULT PSYCHIATRIC CLINIC
Other - Org Name:NORTH CENTRAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:PEABODY
Authorized Official - Suffix:
Authorized Official - Credentials:MA, CSW
Authorized Official - Phone:313-369-1717
Mailing Address - Street 1:17141 RYAN RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48212-1112
Mailing Address - Country:US
Mailing Address - Phone:313-369-1717
Mailing Address - Fax:313-892-0137
Practice Address - Street 1:17141 RYAN RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48212-1112
Practice Address - Country:US
Practice Address - Phone:313-369-1717
Practice Address - Fax:313-369-1728
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2013-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1706446101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI71020000H26282OtherBLUE CROSS BLUE SHIELD ID
MI1706446Medicaid
MI1706446Medicaid
MI0H26282Medicare PIN