Healthcare Provider Details

I. General information

NPI: 1790477099
Provider Name (Legal Business Name): CLINICAL HEALING CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 12/15/2023
Certification Date: 12/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 CROCKER BLVD STE 100
MOUNT CLEMENS MI
48043-2558
US

IV. Provider business mailing address

35181 PLEASANT FARM RD
RICHMOND MI
48062-4235
US

V. Phone/Fax

Practice location:
  • Phone: 586-318-4221
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. TIMOTHY LEE WEAVER
Title or Position: CLINICIAN
Credential: LMSW, CAADC
Phone: 586-318-4221