Provider Demographics
NPI:1972860005
Name:SAMARITAS LUTHERAN SOCIAL SERVICES OF MICHIGAN
Entity Type:Organization
Organization Name:SAMARITAS LUTHERAN SOCIAL SERVICES OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:CEDERSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-308-2764
Mailing Address - Street 1:8131 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-2610
Mailing Address - Country:US
Mailing Address - Phone:269-345-5776
Mailing Address - Fax:269-345-4011
Practice Address - Street 1:128 S COCHRAN AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:MI
Practice Address - Zip Code:48813-1510
Practice Address - Country:US
Practice Address - Phone:517-325-9090
Practice Address - Fax:517-325-9091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-13
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 103TA0400X, 104100000X, 2084A0401X, 251S00000X, 261QM1300X
MICB390258392253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)Group - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Multi-Specialty
No251S00000XAgenciesCommunity/Behavioral HealthGroup - Multi-Specialty
No253J00000XAgenciesFoster Care Agency
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty