Provider Demographics
NPI:1922832914
Name:DREWERY, RICO DAMON JR (LLC)
Entity type:Individual
Prefix:
First Name:RICO
Middle Name:DAMON
Last Name:DREWERY
Suffix:JR
Gender:M
Credentials:LLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19311 OLD HOMESTEAD DR
Mailing Address - Street 2:
Mailing Address - City:HARPER WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48225-2040
Mailing Address - Country:US
Mailing Address - Phone:248-929-1061
Mailing Address - Fax:
Practice Address - Street 1:3505 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-6559
Practice Address - Country:US
Practice Address - Phone:734-323-2043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health