Healthcare Provider Details

I. General information

NPI: 1902517279
Provider Name (Legal Business Name): ELYSIAN COUNSELING, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2022
Last Update Date: 12/07/2022
Certification Date: 12/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12663 CLINTON RD
CLINTON MI
49236-9670
US

IV. Provider business mailing address

12663 CLINTON RD
CLINTON MI
49236-9670
US

V. Phone/Fax

Practice location:
  • Phone: 734-548-3606
  • Fax:
Mailing address:
  • Phone: 734-548-3606
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: TAMI MORENO
Title or Position: PSYCHOTHERAPIST/OWNER
Credential: LMSW - CLINICAL
Phone: 734-548-3606