Provider Demographics
NPI:1104435460
Name:GODDESS GREAT
Entity type:Organization
Organization Name:GODDESS GREAT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KYMALETHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:LLPC
Authorized Official - Phone:269-414-5907
Mailing Address - Street 1:10728 DUPREY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-1295
Mailing Address - Country:US
Mailing Address - Phone:269-414-5907
Mailing Address - Fax:
Practice Address - Street 1:17169 E WARREN AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-2279
Practice Address - Country:US
Practice Address - Phone:313-856-9192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-23
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Single Specialty
Yes251B00000XAgenciesCase Management
No261QF0050XAmbulatory Health Care FacilitiesClinic/CenterFamily Planning, Non-Surgical