Healthcare Provider Details

I. General information

NPI: 1548637143
Provider Name (Legal Business Name): RE- CONNECT MY LIFE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2015
Last Update Date: 03/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1121 VILLA LINDE CT
FLINT MI
48532-3410
US

IV. Provider business mailing address

PO BOX 320414
FLINT MI
48532-0008
US

V. Phone/Fax

Practice location:
  • Phone: 810-515-1931
  • Fax:
Mailing address:
  • Phone: 810-515-1931
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SHUNTAI WALKER
Title or Position: CLINICAL OWNER
Credential:
Phone: 810-515-1931