Healthcare Provider Details

I. General information

NPI: 1194636696
Provider Name (Legal Business Name): MOOD THERAPY AND WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11917 WHISPERING OAK LN
SHELBY TOWNSHIP MI
48315-1173
US

IV. Provider business mailing address

625 KENMOOR AVE SE STE 350
GRAND RAPIDS MI
49546-2395
US

V. Phone/Fax

Practice location:
  • Phone: 248-274-4622
  • Fax:
Mailing address:
  • Phone: 248-274-4622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State

VIII. Authorized Official

Name: ASHLEY DEMENIUK
Title or Position: OWNER, THERAPIST
Credential: LLP
Phone: 248-274-4622