Healthcare Provider Details

I. General information

NPI: 1255172276
Provider Name (Legal Business Name): IRIS WELLNESS CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2024
Last Update Date: 04/23/2026
Certification Date: 04/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

359 LIVERNOIS ST STE 202
FERNDALE MI
48220-2676
US

IV. Provider business mailing address

359 LIVERNOIS ST STE 202
FERNDALE MI
48220-2676
US

V. Phone/Fax

Practice location:
  • Phone: 248-256-5417
  • Fax:
Mailing address:
  • Phone: 248-256-5417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: OLENA TETYUK
Title or Position: OWNER
Credential:
Phone: 248-256-5417