Provider Demographics
NPI:1134341092
Name:NCADD-IMPACT ADOLESCENT HEALTH CENTER
Entity type:Organization
Organization Name:NCADD-IMPACT ADOLESCENT HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:LAVERNE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:MCGLOTHIAN
Authorized Official - Suffix:
Authorized Official - Credentials:FOADP
Authorized Official - Phone:313-921-8102
Mailing Address - Street 1:488 FRAZIER ST
Mailing Address - Street 2:
Mailing Address - City:RIVER ROUGE
Mailing Address - State:MI
Mailing Address - Zip Code:48218-1025
Mailing Address - Country:US
Mailing Address - Phone:313-551-3815
Mailing Address - Fax:
Practice Address - Street 1:5555 CONNER ST
Practice Address - Street 2:2000 NORTH
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3448
Practice Address - Country:US
Practice Address - Phone:313-921-8102
Practice Address - Fax:313-921-4184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-02
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIC1820235935324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility