Healthcare Provider Details

I. General information

NPI: 1396170130
Provider Name (Legal Business Name): SLC THERAPY, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29240 BUCKINGHAM ST SUITE 5
LIVONIA MI
48154-4575
US

IV. Provider business mailing address

29240 BUCKINGHAM SUITE 5
LIVONIA WAYNE
48154
UM

V. Phone/Fax

Practice location:
  • Phone: 866-752-0899
  • Fax: 203-604-0602
Mailing address:
  • Phone: 866-752-0899
  • Fax: 203-604-0602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number11212642
License Number StateWV

VIII. Authorized Official

Name: LANDRIA MONIQUE SEALS GREEN
Title or Position: EXECUTIVE DIRECTOR
Credential: CCC-SLP
Phone: 866-752-0899