Healthcare Provider Details

I. General information

NPI: 1568278992
Provider Name (Legal Business Name): EXTRAORDINARY MINDS THERAPY PRACTICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/10/2024
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 KERCHEVAL AVE STE 370
GROSSE POINTE FARMS MI
48236-3647
US

IV. Provider business mailing address

21 KERCHEVAL AVE STE 370
GROSSE POINTE FARMS MI
48236-3647
US

V. Phone/Fax

Practice location:
  • Phone: 313-969-0196
  • Fax:
Mailing address:
  • Phone: 313-969-0196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. ARIANNA M ZIMMERMAN
Title or Position: CLINICAL PSYCHOTHERAPIST
Credential: LMSW, CST
Phone: 313-969-0196