Provider Demographics
NPI:1992073548
Name:IMPACT COMMUNITY SERVICES
Entity type:Organization
Organization Name:IMPACT COMMUNITY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:ANITRA
Authorized Official - Middle Name:SHAWNTA
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:LLMSW
Authorized Official - Phone:1866-538-2131
Mailing Address - Street 1:18701 GRAND RIVER AVE
Mailing Address - Street 2:SUITE 345
Mailing Address - City:DETROIT
Mailing Address - State:MICHIGAN
Mailing Address - Zip Code:48223
Mailing Address - Country:UM
Mailing Address - Phone:866-538-2131
Mailing Address - Fax:855-284-2226
Practice Address - Street 1:18353 W MCNICHOLS RD
Practice Address - Street 2:SUITE #6
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-4199
Practice Address - Country:US
Practice Address - Phone:866-538-2131
Practice Address - Fax:855-284-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-11
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010917751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty