Provider Demographics
NPI:1003631987
Name:OUTSIDETHEBOX DETROIT THERAPY
Entity type:Organization
Organization Name:OUTSIDETHEBOX DETROIT THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:ALLAN
Authorized Official - Last Name:LAKE
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:313-680-0019
Mailing Address - Street 1:23131 MICHIGAN AVE # 1046
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2020
Mailing Address - Country:US
Mailing Address - Phone:313-680-0019
Mailing Address - Fax:
Practice Address - Street 1:4131 CLIPPERT ST
Practice Address - Street 2:
Practice Address - City:DEARBORN HTS
Practice Address - State:MI
Practice Address - Zip Code:48125-2732
Practice Address - Country:US
Practice Address - Phone:313-680-0019
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty