Healthcare Provider Details

I. General information

NPI: 1184499113
Provider Name (Legal Business Name): SELF LED THERAPY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2970 E LAKE LANSING RD
EAST LANSING MI
48823-7415
US

IV. Provider business mailing address

5966 HARPER RD
HOLT MI
48842-8618
US

V. Phone/Fax

Practice location:
  • Phone: 810-513-4976
  • Fax:
Mailing address:
  • Phone: 810-513-4976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: RACHEL LEEANN BENTLEY
Title or Position: CEO/OWNER
Credential: LPC
Phone: 810-513-4976