Healthcare Provider Details

I. General information

NPI: 1427786649
Provider Name (Legal Business Name): BLUEMIND THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 08/12/2023
Certification Date: 08/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2395 S HURON PKWY
ANN ARBOR MI
48104-5170
US

IV. Provider business mailing address

38445 TERRY LN
WESTLAND MI
48185-7657
US

V. Phone/Fax

Practice location:
  • Phone: 313-870-7204
  • Fax:
Mailing address:
  • Phone: 313-870-7204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name: MOHAMDALI MAZLOUM
Title or Position: OWNER
Credential:
Phone: 313-870-7204