=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356719231
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AT PEACE GUIDANCE SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2015
-----------------------------------------------------
Last Update Date | 04/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16110 KING RD
-----------------------------------------------------
City | RIVERVIEW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48193-7944
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-365-6764
-----------------------------------------------------
Fax | 734-621-6318
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2059
-----------------------------------------------------
City | TAYLOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48180-8959
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-365-6764
-----------------------------------------------------
Fax | 734-621-6318
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MS. TANYA BROOKS
-----------------------------------------------------
Credential | MA, LPC
-----------------------------------------------------
Telephone | 734-365-6764
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 6401010824
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------