Healthcare Provider Details

I. General information

NPI: 1114881059
Provider Name (Legal Business Name): INTENTIONAL WELLNESS PSYCHOTHERAPY, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29532 SOUTHFIELD RD STE 115
SOUTHFIELD MI
48076-2023
US

IV. Provider business mailing address

29532 SOUTHFIELD RD STE 115
SOUTHFIELD MI
48076-2023
US

V. Phone/Fax

Practice location:
  • Phone: 269-359-0759
  • Fax:
Mailing address:
  • Phone: 269-359-0759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: KATE ADA FITZSIMONS
Title or Position: CLINICAL SOCIAL WORKER/OWNER
Credential: LMSW
Phone: 269-359-0759