Provider Demographics
NPI:1831757988
Name:WINDOM, CARLOS F SR (LLPC)
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:F
Last Name:WINDOM
Suffix:SR
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48216-2200
Mailing Address - Country:US
Mailing Address - Phone:313-554-0485
Mailing Address - Fax:313-228-0283
Practice Address - Street 1:20901 MOROSS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48236-2058
Practice Address - Country:US
Practice Address - Phone:313-626-2600
Practice Address - Fax:313-626-2605
Is Sole Proprietor?:No
Enumeration Date:2019-06-04
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401016370101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No101Y00000XBehavioral Health & Social Service ProvidersCounselor