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General NPI Number Information
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NPI Number | 1225520133
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Entity Type | Organization
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Legal Business Name | LANDMARK THERAPY LLC
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Dates
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Enumeration Date | 06/06/2018
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Last Update Date | 06/06/2018
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Provider Practice Location Address
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Address Line | 28330 FRANKLIN RIVER DR
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City | SOUTHFIELD
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State | MI
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Zip | 48034-5479
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Country | US
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Telephone | 810-875-9186
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Fax |
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Provider Business Mailing Address
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Address Line | 1848 HUMPHREY AVE
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City | BIRMINGHAM
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State | MI
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Zip | 48009-7153
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Country | US
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Telephone | 810-875-9186
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Fax |
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Authorized Official
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Title or Position | CLINICAL DIRECTOR
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Name | JAMES COUNCIL WICKERSHAM
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Credential | LMSW
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Telephone | 248-931-0016
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number |
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License Number State |
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