Healthcare Provider Details

I. General information

NPI: 1790446433
Provider Name (Legal Business Name): THE (B)RESOURCE ROOM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 01/05/2022
Certification Date: 01/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19532 WESTPHALIA ST
DETROIT MI
48205-1734
US

IV. Provider business mailing address

19532 WESTPHALIA ST
DETROIT MI
48205-1734
US

V. Phone/Fax

Practice location:
  • Phone: 313-564-7204
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: BREONNA JONES
Title or Position: OWNER
Credential:
Phone: 313-564-7204