Healthcare Provider Details

I. General information

NPI: 1417739624
Provider Name (Legal Business Name): IMPACT LIFE SOLUTIONS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4204 BUCKINGHAM AVE
DETROIT MI
48224-3539
US

IV. Provider business mailing address

4204 BUCKINGHAM AVE
DETROIT MI
48224-3539
US

V. Phone/Fax

Practice location:
  • Phone: 248-571-4806
  • Fax:
Mailing address:
  • Phone: 248-571-4806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: DR. KELLEY MAYS
Title or Position: OWNER / THERAPIST
Credential: DMIN
Phone: 248-571-4806