Healthcare Provider Details

I. General information

NPI: 1053297630
Provider Name (Legal Business Name): REWIRE YOUR MIND BEHAVIORAL HEALTH COUNSELING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2025
Last Update Date: 08/11/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S 3RD ST STE 120
SAINT CLAIR MI
48079-5369
US

IV. Provider business mailing address

110 S 3RD ST STE 120
SAINT CLAIR MI
48079-5369
US

V. Phone/Fax

Practice location:
  • Phone: 810-858-8818
  • Fax: 810-858-8818
Mailing address:
  • Phone: 810-858-8818
  • Fax: 810-858-8818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MS. GABRIELA MARITA VEGA
Title or Position: PRESIDENT
Credential: LMSW-C
Phone: 810-858-8818