MEDICARE: ARBORETUM CONTEMPORARY PSYCHODYNAMICS, 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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

General Provider Information

NPI Number	:	1538833660
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ARBORETUM CONTEMPORARY PSYCHODYNAMICS, LLC

Provider Business Mailing Address
First Line	:	4807 COMMONWEALTH ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48208-2227
Country	:	US
Telephone Number	:	313-355-0534
Fax Number	:

Provider Business Practice Location Address
First Line	:	4807 COMMONWEALTH ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48208-2227
Country	:	US
Telephone Number	:	313-355-0534
Fax Number	:

Authorized Official
Title or Position	:	PRINCIPAL
Name	:	JACALYN HARDEN
Credential	:
Telephone Number	:	313-355-0534

Provider Enumeration Date	:	08/03/2021
Last Update Date	:	08/03/2021

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