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General NPI Number Information
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NPI Number | 1265284798
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Entity Type | Organization
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Legal Business Name | OUT THE BOX THERAPY LLC
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Dates
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Enumeration Date | 04/05/2024
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Last Update Date | 10/01/2024
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Provider Practice Location Address
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Address Line | 5215 BRADMORE LN
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City | WARREN
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State | MI
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Zip | 48092-6322
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Country | US
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Telephone | 734-678-1363
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Fax |
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Provider Business Mailing Address
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Address Line | 921 LULWORTH LN
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City | LAWRENCEVILLE
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State | GA
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Zip | 30044-2760
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Country | US
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Telephone | 734-678-1363
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | CLARA THROCKMORTON
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Credential | LCSW
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Telephone | 734-678-1363
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number |
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License Number State |
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