Healthcare Provider Details

I. General information

NPI: 1164206116
Provider Name (Legal Business Name): STORY ROAD THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29551 GREENFIELD RD STE 212
SOUTHFIELD MI
48076-5872
US

IV. Provider business mailing address

29551 GREENFIELD RD STE 212
SOUTHFIELD MI
48076-5872
US

V. Phone/Fax

Practice location:
  • Phone: 248-221-2718
  • Fax:
Mailing address:
  • Phone: 248-221-2718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: MARQUITTA FIELDS
Title or Position: OWNER
Credential: LMFT
Phone: 248-221-2718