Healthcare Provider Details

I. General information

NPI: 1518412733
Provider Name (Legal Business Name): RESTORATIVE COUNSELING SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29661 RED LEAF DR
SOUTHFIELD MI
48076-2040
US

IV. Provider business mailing address

29661 RED LEAF DR
SOUTHFIELD MI
48076-2040
US

V. Phone/Fax

Practice location:
  • Phone: 313-304-1120
  • Fax: 248-443-6623
Mailing address:
  • Phone: 313-304-1120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MARK ELLORY WINSTON
Title or Position: CEO
Credential:
Phone: 313-304-1120