Provider Demographics
NPI:1700344074
Name:YOUTHQUAKE PLLC
Entity Type:Organization
Organization Name:YOUTHQUAKE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-FOUNDER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARNI
Authorized Official - Middle Name:LAUREN
Authorized Official - Last Name:HUS
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-505-0558
Mailing Address - Street 1:6760 LESLEE CREST DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3722
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6760 LESLEE CREST DR
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3722
Practice Address - Country:US
Practice Address - Phone:248-505-0558
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI16290403068Medicaid