Provider Demographics
NPI:1972964203
Name:PRESCOTT, KIRK D (AODA)
Entity type:Individual
Prefix:MR
First Name:KIRK
Middle Name:D
Last Name:PRESCOTT
Suffix:
Gender:M
Credentials:AODA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16055 EDWARD ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-2717
Mailing Address - Country:US
Mailing Address - Phone:313-867-8015
Mailing Address - Fax:313-867-8040
Practice Address - Street 1:300 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48203-2703
Practice Address - Country:US
Practice Address - Phone:313-867-8015
Practice Address - Fax:313-867-8040
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility