Healthcare Provider Details

I. General information

NPI: 1376011312
Provider Name (Legal Business Name): ROMMARK BALTAZAR MANLIMOS LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2018
Last Update Date: 03/27/2026
Certification Date: 03/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 GENOA BUSINESS PARK DR STE 100
BRIGHTON MI
48114-5328
US

IV. Provider business mailing address

1100 TORREY RD STE 100
FENTON MI
48430-3327
US

V. Phone/Fax

Practice location:
  • Phone: 810-449-7180
  • Fax: 248-692-4936
Mailing address:
  • Phone: 810-494-7180
  • Fax: 248-692-4936

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLF61483490
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCP00005654
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4151001008
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: