MEDICARE: CULTIVATING HOPE COLLABORATIVE THERAPY, PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1376850867	OTHER	MI	LARA

General Provider Information

NPI Number	:	1104592450
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CULTIVATING HOPE COLLABORATIVE THERAPY, PLC

Provider Business Mailing Address
First Line	:	25600 WOODWARD AVE STE 109
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-0944
Country	:	US
Telephone Number	:	734-926-9337
Fax Number	:	734-423-1419

Provider Business Practice Location Address
First Line	:	25600 WOODWARD AVE STE 109
Second Line	:
City	:	ROYAL OAK
State	:	MI
Zip	:	48067-0944
Country	:	US
Telephone Number	:	734-926-9337
Fax Number	:	734-423-1419

Authorized Official
Title or Position	:	LIMITED LICENSED PSYCHOLOGIST
Name	:	MICHELE L THOMPSON
Credential	:	MS
Telephone Number	:	419-205-3801

Provider Enumeration Date	:	08/17/2021
Last Update Date	:	08/17/2021

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