Healthcare Provider Details

I. General information

NPI: 1619451655
Provider Name (Legal Business Name): ANXIETY WELLNESS PROGRAM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/15/2018
Last Update Date: 07/30/2020
Certification Date: 07/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 N LIVERNOIS RD
ROCHESTER HILLS MI
48307-1001
US

IV. Provider business mailing address

53375 WHITBY WAY
SHELBY TOWNSHIP MI
48316-2751
US

V. Phone/Fax

Practice location:
  • Phone: 586-291-7557
  • Fax:
Mailing address:
  • Phone: 586-291-7557
  • 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 Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MRS. GABRIELA ZAMORA-AHLSTROM
Title or Position: CLINICAL DIRECTOR
Credential: LCSW
Phone: 586-291-7557