Healthcare Provider Details

I. General information

NPI: 1063093292
Provider Name (Legal Business Name): I'M YOUR THERAPIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1715 INDIAN WOOD CIRCLE STE 200
MAUMEE OH
43537
US

IV. Provider business mailing address

1715 INDIAN WOOD CIR STE 200
MAUMEE OH
43537-4055
US

V. Phone/Fax

Practice location:
  • Phone: 269-339-8531
  • Fax:
Mailing address:
  • Phone: 269-339-8531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
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: DIANA ORNS-GRANT
Title or Position: OWNER
Credential: LISW
Phone: 269-339-8531