Healthcare Provider Details

I. General information

NPI: 1891303012
Provider Name (Legal Business Name): MINDFUL CONCEPTS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2020
Last Update Date: 07/14/2020
Certification Date: 07/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21650 W 11 MILE RD STE 108
SOUTHFIELD MI
48076-3715
US

IV. Provider business mailing address

29305 POINTE O WOODS PL APT 207
SOUTHFIELD MI
48034-1241
US

V. Phone/Fax

Practice location:
  • Phone: 248-919-8473
  • Fax:
Mailing address:
  • Phone: 313-247-4413
  • 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 Code102L00000X
TaxonomyPsychoanalyst
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code103TP2701X
TaxonomyGroup Psychotherapy Psychologist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: JUANIKA L. BENSON
Title or Position: PSYCHOTHERAPIST
Credential: LLP
Phone: 313-247-4413