Organization
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Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. LATASHA CHARLENE PEMBERTON DCE (PROVIDER)
(313) 743-2462
Entity
Organization
Contact information
Practice address
24145 GRANGE ST, CLINTON TOWNSHIP, MI 48036-3008
(313) 743-2462
Mailing address
24145 GRANGE ST, CLINTON TOWNSHIP, MI 48036-3008
Taxonomy
Speciality
Code
Description
License number
State
320800000X
Mental Illness Community Based Residential Treatment Facility
Primary
—
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Other
Enumeration date
04/16/2009
Last updated
04/16/2009
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