Healthcare Provider Details

I. General information

NPI: 1881462984
Provider Name (Legal Business Name): ORIGINS THERAPY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18980 SANTA BARBARA DR
DETROIT MI
48221-2152
US

IV. Provider business mailing address

18980 SANTA BARBARA DR
DETROIT MI
48221-2152
US

V. Phone/Fax

Practice location:
  • Phone: 313-974-9875
  • Fax:
Mailing address:
  • Phone: 313-974-9875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARIA ISABELLE LOCKHART
Title or Position: CEO/FOUNDER/PSYCHOTHERAPIST
Credential: LMSW
Phone: 313-974-9875