=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437880812
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALING MIRACLES THERAPY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2022
-----------------------------------------------------
Last Update Date | 03/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 18303 E 10 MILE RD STE 200
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48066-4989
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-445-6920
-----------------------------------------------------
Fax | 586-204-0379
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30550 GRATIOT AVE UNIT 66069
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48066-6731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-445-6920
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL SOCIAL WORKER
-----------------------------------------------------
Name | LONDON WILSON
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 313-445-6920
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------