=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407678915
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUND MIND CHRISTIAN COUNSELING SERVICES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2024
-----------------------------------------------------
Last Update Date | 10/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8401 PURITAN ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48238-1158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-470-9941
-----------------------------------------------------
Fax | 734-992-5680
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8401 PURITAN ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48238-1158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-470-9941
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. AGGIE JOHNSON
-----------------------------------------------------
Credential | LMSW-C
-----------------------------------------------------
Telephone | 313-587-2041
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------