Provider Demographics
NPI:1215928643
Name:SPECTRUM REHABILITATION CENTERS INC
Entity type:Organization
Organization Name:SPECTRUM REHABILITATION CENTERS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:G
Authorized Official - Last Name:SEWICK
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:248-350-3650
Mailing Address - Street 1:26555 EVERGREEN RD
Mailing Address - Street 2:STE 830
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-4206
Mailing Address - Country:US
Mailing Address - Phone:248-350-3650
Mailing Address - Fax:248-350-1216
Practice Address - Street 1:26555 EVERGREEN RD
Practice Address - Street 2:STE 830
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-4206
Practice Address - Country:US
Practice Address - Phone:248-350-3650
Practice Address - Fax:248-350-1216
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-03
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301005256103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1193960001Medicaid
MI1193960001Medicaid