Provider Demographics
NPI:1427355049
Name:MICHIGAN BEHAVIORAL WELLNESS LLC
Entity type:Organization
Organization Name:MICHIGAN BEHAVIORAL WELLNESS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:SANYANI
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:PSY,S
Authorized Official - Phone:248-677-1564
Mailing Address - Street 1:28157 DEQUINDRE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-3046
Mailing Address - Country:US
Mailing Address - Phone:248-677-1564
Mailing Address - Fax:
Practice Address - Street 1:1386 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-3104
Practice Address - Country:US
Practice Address - Phone:313-908-0172
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-16
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty