Provider Demographics
NPI:1063965432
Name:FOSTER, DOROTHEA
Entity type:Individual
Prefix:
First Name:DOROTHEA
Middle Name:
Last Name:FOSTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 PINGREE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2024
Mailing Address - Country:US
Mailing Address - Phone:313-932-5527
Mailing Address - Fax:313-784-9612
Practice Address - Street 1:29623 NORTHWESTERN HWY STE 6
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-1076
Practice Address - Country:US
Practice Address - Phone:313-932-5527
Practice Address - Fax:313-731-1991
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MI6401019634101YP2500X
MI6401016226101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1063965432Medicaid
MI6401019634OtherMENTAL/ BEHAVIORAL HEALTH