| Lake Huron Center Llc | |
|
2870 E Grand Blvd Ste 600 Detroit MI 48202-3120 | |
| (313) 736-5041 | |
| Not Available |
| Full Name | Lake Huron Center Llc |
|---|---|
| Speciality | Counselor |
| Location | 2870 E Grand Blvd Ste 600, Detroit, Michigan |
| Authorized Official Name and Position | Jerrolynn Justusson (PRESIDENT) |
| Authorized Official Contact | 8007430396 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Lake Huron Center Llc 2870 E Grand Blvd Ste 600 Detroit MI 48202-3120 Ph: (313) 736-5041 | Lake Huron Center Llc 2870 E Grand Blvd Ste 600 Detroit MI 48202-3120 Ph: (313) 736-5041 |
| NPI Number | 1699543777 |
|---|---|
| Provider Enumeration Date | 12/18/2023 |
| Last Update Date | 12/18/2023 |
| Certification Date | 12/18/2023 |
| Medicare PECOS PAC ID | 0840635249 |
|---|---|
| Medicare Enrollment ID | O20240226000841 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1699543777 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 101YA0400X | Counselor - Addiction (substance Use Disorder) | (* (Not Available)) | Primary |
| Provider Name | Padgett D Vanhoutteghem |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1679622633 PECOS PAC ID: 6103940507 Enrollment ID: I20100909001229 |
| Provider Name | Shanti Turner |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1265955538 PECOS PAC ID: 9537504931 Enrollment ID: I20240226000678 |
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