Healthcare Provider Details

I. General information

NPI: 1598470320
Provider Name (Legal Business Name): DBT GYM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2023
Last Update Date: 01/16/2023
Certification Date: 01/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25430 SOUTHFIELD RD # A102
SOUTHFIELD MI
48075-1957
US

IV. Provider business mailing address

25430 SOUTHFIELD RD # A102
SOUTHFIELD MI
48075-1957
US

V. Phone/Fax

Practice location:
  • Phone: 248-763-2399
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SHAYLA GLASS
Title or Position: THERAPIST
Credential: LLP
Phone: 248-763-2399