MEDICARE: THE MINDFUL SELF, LLC

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	6301024395	MI
2	101YP2500X	Professional Counselor	6401011013	MI

General Provider Information

NPI Number	:	1477805463
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE MINDFUL SELF, LLC

Provider Business Mailing Address
First Line	:	31201 CHICAGO RD S STE A201
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48093-5552
Country	:	US
Telephone Number	:	248-543-0033
Fax Number	:	248-548-5309

Provider Business Practice Location Address
First Line	:	31201 CHICAGO RD S STE A201
Second Line	:
City	:	WARREN
State	:	MI
Zip	:	48093-5552
Country	:	US
Telephone Number	:	248-543-0033
Fax Number	:	248-548-5309

Authorized Official
Title or Position	:	CLINICAL PSYCHOLOGIST
Name	:	DR. ALISA M HILEWSKY
Credential	:	PSYD, LLP, LPC
Telephone Number	:	248-543-0033

Provider Enumeration Date	:	10/15/2012
Last Update Date	:	12/12/2024

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Directions to “THE MINDFUL SELF, LLC ” Practice Location

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