1174636682 NPI number — MRS. CASSANDRA CLEOTHA SHERIFF MS, SST

Table of content: MRS. CASSANDRA CLEOTHA SHERIFF MS, SST (NPI 1174636682)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174636682 NPI number — MRS. CASSANDRA CLEOTHA SHERIFF MS, SST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHERIFF
Provider First Name:
CASSANDRA
Provider Middle Name:
CLEOTHA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS, SST
Provider Gender Code:
F

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:
1174636682
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
23061 KIPLING ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OAK PARK
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48237-2019
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-575-5531
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19170 EUREKA RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHGATE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48195-2985
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-324-8326
Provider Business Practice Location Address Fax Number:
734-324-8327
Provider Enumeration Date:
08/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  6803085306 , 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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