Provider Demographics
NPI:1023116480
Name:CROSSROADS GROUP, LLC
Entity type:Organization
Organization Name:CROSSROADS GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DORELLA
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:BOND
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:734-660-4828
Mailing Address - Street 1:667 KUEHNLE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-2608
Mailing Address - Country:US
Mailing Address - Phone:734-660-4828
Mailing Address - Fax:734-994-9722
Practice Address - Street 1:667 KUEHNLE ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-2608
Practice Address - Country:US
Practice Address - Phone:734-660-4828
Practice Address - Fax:734-994-9722
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-20
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012697103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT060001850CT01OtherBC/BS OF CT
MI1780613885OtherINDIVIDUAL NPI
MI68-0-F3-3231-0OtherBC/BS OF MI
MI68-0-F3-3231-0OtherBC/BS OF MI