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General NPI Number Information
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NPI Number | 1013145879
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Entity Type | Organization
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Legal Business Name | MINDFUL LIVING PLLC
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Dates
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Enumeration Date | 06/30/2009
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Last Update Date | 06/30/2009
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Provider Practice Location Address
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Address Line | 810 E GRAND RIVER AVE STE 101
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City | BRIGHTON
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State | MI
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Zip | 48116-1878
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Country | US
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Telephone | 810-588-4236
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Fax | 810-588-4247
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Provider Business Mailing Address
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Address Line | 2460 CARRIAGE WAY
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City | YPSILANTI
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State | MI
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Zip | 48197-7423
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Country | US
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Telephone | 734-657-8059
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Fax | 810-588-4247
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | DR. DEBBIE KOELTZOW
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Credential | ED.D., LP
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Telephone | 734-657-8059
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6301011430
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License Number State | MI
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