1306243225 NPI number — MRS. DEBRA T HURSEY-LEE BACHELOR

Table of content: MRS. DEBRA T HURSEY-LEE BACHELOR (NPI 1306243225)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306243225 NPI number — MRS. DEBRA T HURSEY-LEE BACHELOR

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HURSEY-LEE
Provider First Name:
DEBRA
Provider Middle Name:
T
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
BACHELOR
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BEARD
Provider Other First Name:
SANDY
Provider Other Middle Name:
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MSW
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1306243225
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8627 WOODWARD AVE
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:
48202-2141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-870-9372
Provider Business Mailing Address Fax Number:
313-871-0143

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40 MASSACHUSETTS ST
Provider Second Line Business Practice Location Address:
NONE
Provider Business Practice Location Address City Name:
HIGHLAND PARK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48203-3537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-731-7133
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/20/2014

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: 171M00000X , with the licence number:  6801081452 , 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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