Healthcare Provider Details

I. General information

NPI: 1255146965
Provider Name (Legal Business Name): MYND THERA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19815 MACK AVE STE B
GROSSE POINTE WOODS MI
48236-2505
US

IV. Provider business mailing address

19815 MACK AVE STE B
GROSSE POINTE WOODS MI
48236-2505
US

V. Phone/Fax

Practice location:
  • Phone: 313-516-7143
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
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: NICHOLAS MISCHEL
Title or Position: OWNER
Credential: MD
Phone: 313-516-7143