MEDICARE: PEACE AND MIND THERAPY CENTER

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	1041C0700X	Clinical Social Worker

General Provider Information

NPI Number	:	1558019315
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PEACE AND MIND THERAPY CENTER

Provider Business Mailing Address
First Line	:	1269 WOODFIELD ST
Second Line	:
City	:	LAKE ORION
State	:	MI
Zip	:	48362-1766
Country	:	US
Telephone Number	:	248-506-6936
Fax Number	:

Provider Business Practice Location Address
First Line	:	1269 WOODFIELD ST
Second Line	:
City	:	LAKE ORION
State	:	MI
Zip	:	48362-1766
Country	:	US
Telephone Number	:	248-506-6936
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	JADE E FREDERICK
Credential	:	LMSW
Telephone Number	:	248-266-0475

Provider Enumeration Date	:	03/11/2022
Last Update Date	:	03/11/2022

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