Healthcare Provider Details

I. General information

NPI: 1003376112
Provider Name (Legal Business Name): STATE OF MIND COUNSELING CENTERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2019
Last Update Date: 06/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52188 VAN DYKE AVE STE 319
SHELBY TOWNSHIP MI
48316-3571
US

IV. Provider business mailing address

140 FONTAINBLEAU CT E
ROCHESTER HILLS MI
48307-2421
US

V. Phone/Fax

Practice location:
  • Phone: 248-690-6851
  • Fax:
Mailing address:
  • Phone: 248-521-8237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: CARRISSA NICOLE MICHAEL
Title or Position: OWNER/THERAPIST
Credential: MA, LPC, NCC, LLMFT
Phone: 248-521-8237