Healthcare Provider Details

I. General information

NPI: 1609781764
Provider Name (Legal Business Name): EMERALD WELLNESS CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 W BIG BEAVER RD STE 780
TROY MI
48084-4745
US

IV. Provider business mailing address

888 W BIG BEAVER RD STE 780
TROY MI
48084-4745
US

V. Phone/Fax

Practice location:
  • Phone: 947-622-4424
  • Fax:
Mailing address:
  • Phone: 947-622-4424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: SAMANTHA BLAIR HOLMAN
Title or Position: LIMITED LICENSED PSYCHOLOGIST
Credential: LLP
Phone: 947-622-4424