Provider Demographics
NPI:1750828141
Name:ELIZABETH UPJOHN COMMUNITY HEALING CENTER
Entity type:Organization
Organization Name:ELIZABETH UPJOHN COMMUNITY HEALING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EARLY CHILDHOOD SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ALISON
Authorized Official - Middle Name:
Authorized Official - Last Name:CIESA
Authorized Official - Suffix:
Authorized Official - Credentials:LLMSW
Authorized Official - Phone:269-271-0229
Mailing Address - Street 1:1603 REDSTOCK AVE
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:MI
Mailing Address - Zip Code:49024-4143
Mailing Address - Country:US
Mailing Address - Phone:269-779-9619
Mailing Address - Fax:
Practice Address - Street 1:1603 REDSTOCK AVE
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49024-4143
Practice Address - Country:US
Practice Address - Phone:269-779-9619
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-24
Last Update Date:2017-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency