Healthcare Provider Details

I. General information

NPI: 1528655826
Provider Name (Legal Business Name): MINI MITTEN PEDIATRIC THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2020
Last Update Date: 06/05/2025
Certification Date: 06/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 N TELEGRAPH RD
MONROE MI
48162-9328
US

IV. Provider business mailing address

7447 N TELEGRAPH RD
MONROE MI
48162-9328
US

V. Phone/Fax

Practice location:
  • Phone: 734-888-6464
  • Fax: 734-275-0985
Mailing address:
  • Phone: 734-888-6464
  • Fax: 734-275-0985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CASEY BROSS
Title or Position: OWNER
Credential: OTD, OTRL, CLT, CLC
Phone: 734-888-6464