Organization
CREATING A HEALTHY COMMUNITY
Active
Organization subpart
No
Provider details
NPI number
Authorized official
VIRDELL THOMAS LMSW,CCS,CAADC,SAP, (DIRECTOR)
(313) 588-0101
Entity
Organization
Contact information
Practice address
5575 CONNER ST, SUITE 204, DETROIT, MI 48213-6400
(313) 588-0101
Mailing address
5077 AUDUBON RD, DETROIT, MI 48224-2658
(313) 588-0101
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
822496
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
822496
MICHIGAN SUBSTANCE ABUSE LICENSE
MI
Enumeration date
11/26/2011
Last updated
02/27/2014
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