Healthcare Provider Details

I. General information

NPI: 1689861114
Provider Name (Legal Business Name): BODYWORKS THERAPEUTICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2007
Last Update Date: 01/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31815 SOUTHFIELD RD SUITE 16
BEVERLY HILLS MI
48025-5471
US

IV. Provider business mailing address

28611 LATHRUP BLVD
LATHRUP VILLAGE MI
48076-2849
US

V. Phone/Fax

Practice location:
  • Phone: 248-788-6059
  • Fax:
Mailing address:
  • Phone: 248-798-1657
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302F00000X
TaxonomyExclusive Provider Organization
License NumberBUS200600893
License Number StateMI

VIII. Authorized Official

Name: MRS. LISA YVONNE CRAWFORD
Title or Position: OWNER/PRACTIONER
Credential: LMT, CMT, CBIS
Phone: 248-798-1657