Provider Demographics
NPI:1679380828
Name:DETROIT WAYNE INTEGRATED HEALTH NETWORK
Entity type:Organization
Organization Name:DETROIT WAYNE INTEGRATED HEALTH NETWORK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEER SUPPORT
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISRANDRA
Authorized Official - Middle Name:A
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-955-1500
Mailing Address - Street 1:11501 PETOSKEY AVE APT 328
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-3920
Mailing Address - Country:US
Mailing Address - Phone:313-955-1500
Mailing Address - Fax:
Practice Address - Street 1:707 W MILWAUKEE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2943
Practice Address - Country:US
Practice Address - Phone:313-955-1500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Single Specialty