Healthcare Provider Details

I. General information

NPI: 1477805463
Provider Name (Legal Business Name): THE MINDFUL SELF, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31201 CHICAGO RD S STE A201
WARREN MI
48093-5552
US

IV. Provider business mailing address

31201 CHICAGO RD S STE A201
WARREN MI
48093-5552
US

V. Phone/Fax

Practice location:
  • Phone: 248-543-0033
  • Fax: 248-548-5309
Mailing address:
  • Phone: 248-543-0033
  • Fax: 248-548-5309

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6401011013
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6301024395
License Number StateMI

VIII. Authorized Official

Name: DR. ALISA M HILEWSKY
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSYD, LLP, LPC
Phone: 248-543-0033