1639578941 NPI number — MISS MARSY ALSTON SST, CADC, CPRM, PRC

Table of content: MISS MARSY ALSTON SST, CADC, CPRM, PRC (NPI 1639578941)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639578941 NPI number — MISS MARSY ALSTON SST, CADC, CPRM, PRC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALSTON
Provider First Name:
MARSY
Provider Middle Name:
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
SST, CADC, CPRM, PRC
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:
1639578941
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
707 W MILWAUKEE ST
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:
48202-2943
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-344-9099
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12010 LINWOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48206-1108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-867-1090
Provider Business Practice Location Address Fax Number:
313-867-0706
Provider Enumeration Date:
08/22/2014

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: 101YA0400X , with the licence number:  1-04561 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 175T00000X , 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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