Provider Demographics
NPI:1891978441
Name:WOLVERINE HUMAN SERVICES
Entity Type:Organization
Organization Name:WOLVERINE HUMAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT & CFO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GUMBLETON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-886-4259
Mailing Address - Street 1:17000 E WARREN AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2358
Mailing Address - Country:US
Mailing Address - Phone:313-886-4259
Mailing Address - Fax:313-886-4857
Practice Address - Street 1:150 ENTERPRISE DR
Practice Address - Street 2:
Practice Address - City:VASSAR
Practice Address - State:MI
Practice Address - Zip Code:48768-9584
Practice Address - Country:US
Practice Address - Phone:989-823-3040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-06
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children