=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275373763
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOONFLOWER COUNSELING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2024
-----------------------------------------------------
Last Update Date | 05/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1605 E 13 MILE RD APT 108
-----------------------------------------------------
City | MADISON HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48071-5018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-764-7666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1605 E 13 MILE RD APT 108
-----------------------------------------------------
City | MADISON HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48071-5018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-764-7666
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER
-----------------------------------------------------
Name | LAUREN MARIE WATERS
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 586-764-7666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------