Provider Demographics
NPI:1982899415
Name:ELEANOR MARIE QUALLS
Entity Type:Organization
Organization Name:ELEANOR MARIE QUALLS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:QUALLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-618-6254
Mailing Address - Street 1:20314 FENMORE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48235-2294
Mailing Address - Country:US
Mailing Address - Phone:313-618-6254
Mailing Address - Fax:
Practice Address - Street 1:20314 FENMORE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-2294
Practice Address - Country:US
Practice Address - Phone:313-618-6254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802070438104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty