=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235819376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAISY MENTAL HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2023
-----------------------------------------------------
Last Update Date | 09/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 E MAIN ST STE C
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48167-2679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-845-4654
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18790 DOLORES AVE
-----------------------------------------------------
City | LATHRUP VILLAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-2502
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-417-1542
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OPERATIONS MANAGER
-----------------------------------------------------
Name | DEREK REMER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-417-1542
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------