=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114784774
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COLLECTIVE MIND
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/29/2024
-----------------------------------------------------
Last Update Date | 03/08/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7596 MACOMB ST STE 13
-----------------------------------------------------
City | GROSSE ILE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48138-2205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-308-9537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7596 MACOMB ST STE 13
-----------------------------------------------------
City | GROSSE ILE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48138-2205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-308-9537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MS. MEGAN KATHLEEN REEDY
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 734-308-9537
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------