Healthcare Provider Details

I. General information

NPI: 1093208142
Provider Name (Legal Business Name): ADRIANNA MARISOL PENA-VAN DEN BOSSCHE NCC, LLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ADRIANNA MARISOL PENA

II. Dates (important events)

Enumeration Date: 06/13/2018
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25899 W 12 MILE RD STE 320
SOUTHFIELD MI
48034-8325
US

IV. Provider business mailing address

25899 W 12 MILE RD STE 320
SOUTHFIELD MI
48034-8325
US

V. Phone/Fax

Practice location:
  • Phone: 734-335-4355
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6451023863
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: