Healthcare Provider Details

I. General information

NPI: 1407020993
Provider Name (Legal Business Name): THE HEALING PALACE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2008
Last Update Date: 11/04/2022
Certification Date: 11/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2089 ANITA AVE
GROSSE POINTE WOODS MI
48236-1427
US

IV. Provider business mailing address

2089 ANITA AVE
GROSSE POINTE WOODS MI
48236-1427
US

V. Phone/Fax

Practice location:
  • Phone: 313-459-6707
  • Fax: 313-731-0360
Mailing address:
  • Phone: 313-459-6707
  • Fax: 313-731-0360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number4704208682
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number470408682
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: DR. CHONTAY DETRIA TAYLOR GLENN
Title or Position: FOUNDER AND CEO
Credential: PHD, RN, PMHNP-BC
Phone: 313-459-6707