Healthcare Provider Details

I. General information

NPI: 1184333130
Provider Name (Legal Business Name): CONVO WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2022
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10167 GRAHAM DRIVE
CLARKSTON MI
48348
US

IV. Provider business mailing address

10167 GRAHAM DRIVE
CLARKSTON MI
48348
US

V. Phone/Fax

Practice location:
  • Phone: 248-805-1764
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: JULIAN PROSSER
Title or Position: CEO
Credential:
Phone: 248-459-5833