=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245747609
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PEAK THERAPY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/08/2018
-----------------------------------------------------
Last Update Date | 01/08/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18270 CASCADE DR
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48168-3287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-776-7738
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 18270 CASCADE DR
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48168-3287
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-776-7738
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JEANINE M MADSEN
-----------------------------------------------------
Credential | THERAPIST, MA
-----------------------------------------------------
Telephone | 734-776-7738
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 6401014963
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------