Provider Demographics
NPI:1902279466
Name:ST. JOHN PROVIDENCE COMMUNITY HEALTH
Entity Type:Organization
Organization Name:ST. JOHN PROVIDENCE COMMUNITY HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BEHAVIORAL HEALTH COUNSELOR
Authorized Official - Prefix:MR
Authorized Official - First Name:LONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:313-372-5974
Mailing Address - Street 1:11600 E 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-2112
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11600 E 7 MILE RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-2112
Practice Address - Country:US
Practice Address - Phone:313-372-5974
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-05
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401013184261QM0855X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health