Healthcare Provider Details

I. General information

NPI: 1386133809
Provider Name (Legal Business Name): WOW THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2018
Last Update Date: 05/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 SUPERIOR ST STE A
PORT HURON MI
48060-3771
US

IV. Provider business mailing address

4043 VIOLET AVE
SAINT CLAIR MI
48079-3532
US

V. Phone/Fax

Practice location:
  • Phone: 810-300-6614
  • Fax:
Mailing address:
  • Phone: 810-300-6614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6401016563
License Number StateMI

VIII. Authorized Official

Name: YUVONE MARIE ROGERS
Title or Position: OWNER
Credential: LLPC
Phone: 810-300-6614