1568776086 NPI number — EXEC-U-TECH BEHAVIORAL THERAPY

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568776086 NPI number — EXEC-U-TECH BEHAVIORAL THERAPY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EXEC-U-TECH BEHAVIORAL THERAPY
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568776086
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1804 CAMPAU FARMS CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48207-5164
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-475-0283
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
505 BEECHWOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RIVER ROUGE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48218-1041
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-386-2288
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/27/2010

Additional Information

Authorized Official

Authorized Official Last Name:
KENT
Authorized Official First Name:
AURELIA
Authorized Official Middle Name:
LAFAYE
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
313-475-0283

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  6801091303 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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