Healthcare Provider Details

I. General information

NPI: 1083990485
Provider Name (Legal Business Name): MIND AND BODY HOLISTIC THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/30/2011
Last Update Date: 10/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

440 BURROUGHS ST.
DETROIT MI
48202
US

IV. Provider business mailing address

29 MASSACHUSETTS ST
HIGHLAND PARK MI
48203
US

V. Phone/Fax

Practice location:
  • Phone: 313-422-3109
  • Fax:
Mailing address:
  • Phone: 313-422-3109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801085560
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number6801085560
License Number StateMI

VIII. Authorized Official

Name: SHARIFA HARVEY
Title or Position: CEO/CLINICAL DIRECTOR
Credential: LMSW-SSW
Phone: 313-422-3109