Provider Demographics
NPI:1144524133
Name:BIRMINGHAM MAPLE CLINIC
Entity type:Organization
Organization Name:BIRMINGHAM MAPLE CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LORI
Authorized Official - Middle Name:KANAT
Authorized Official - Last Name:EDELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-646-6659
Mailing Address - Street 1:2075 W BIG BEAVER RD
Mailing Address - Street 2:SUITE 520
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3407
Mailing Address - Country:US
Mailing Address - Phone:248-646-6659
Mailing Address - Fax:248-642-8645
Practice Address - Street 1:2075 W BIG BEAVER RD
Practice Address - Street 2:SUITE 520
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3407
Practice Address - Country:US
Practice Address - Phone:248-646-6659
Practice Address - Fax:248-642-8645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-05
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0F37006Medicare PIN