Provider Demographics
NPI:1780119214
Name:REBIRTH COMMUNITY INCLUSION PROGRAM
Entity type:Organization
Organization Name:REBIRTH COMMUNITY INCLUSION PROGRAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIELF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:TERESA
Authorized Official - Last Name:JEFFERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MA,LLPC,CCS,CAADC
Authorized Official - Phone:313-418-5667
Mailing Address - Street 1:16951 MARYLAND
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48228
Mailing Address - Country:US
Mailing Address - Phone:313-418-5667
Mailing Address - Fax:
Practice Address - Street 1:16951 MARYLAND ST
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2903
Practice Address - Country:US
Practice Address - Phone:313-418-5667
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1902926207Medicaid