Healthcare Provider Details

I. General information

NPI: 1053008136
Provider Name (Legal Business Name): E SQUARED BEHAVIORAL HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 04/19/2023
Certification Date: 04/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 BEDFORD RD
GROSSE POINTE PARK MI
48230-1116
US

IV. Provider business mailing address

1204 BEDFORD RD
GROSSE POINTE PARK MI
48230-1116
US

V. Phone/Fax

Practice location:
  • Phone: 313-451-1685
  • Fax:
Mailing address:
  • Phone: 313-451-1685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. JASON ELDRED
Title or Position: OWNER
Credential: LPC
Phone: 313-451-1685