1629746664 NPI number — MELANATED CROWN MENTAL HEALTH AND CONSULTING SERVICES

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 1629746664 NPI number — MELANATED CROWN MENTAL HEALTH AND CONSULTING SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MELANATED CROWN MENTAL HEALTH AND CONSULTING SERVICES
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:
1629746664
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/08/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9517 LAKESIDE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YPSILANTI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48197-3033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
40315 MICHIGAN AVE # 1081
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48188-2908
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-431-8503
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/03/2021

Additional Information

Authorized Official

Authorized Official Last Name:
LEGG
Authorized Official First Name:
NERISSA
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
734-431-8503

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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