Healthcare Provider Details

I. General information

NPI: 1215568340
Provider Name (Legal Business Name): COMPLETE KETAMINE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2020
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 WINCHESTER ST
MONROE MI
48161-1957
US

IV. Provider business mailing address

98 WINCHESTER ST
MONROE MI
48161-1957
US

V. Phone/Fax

Practice location:
  • Phone: 734-731-9500
  • Fax:
Mailing address:
  • Phone: 734-731-9500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MISS AMY WERTENBERGER
Title or Position: CLINICAL DIRECTOR
Credential: LPC
Phone: 734-931-6004