Healthcare Provider Details

I. General information

NPI: 1720993439
Provider Name (Legal Business Name): MIRACLE MYNDZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24380 ORCHARD LAKE RD
FARMINGTON HILLS MI
48336-1971
US

IV. Provider business mailing address

24380 ORCHARD LAKE RD
FARMINGTON HILLS MI
48336-1971
US

V. Phone/Fax

Practice location:
  • Phone: 248-880-9023
  • Fax:
Mailing address:
  • Phone: 248-880-9023
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MONIQUE TUCKER
Title or Position: FOUNDER
Credential: PH.D
Phone: 248-880-9023