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General NPI Number Information
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NPI Number | 1477151751
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Entity Type | Organization
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Legal Business Name | FULLY ALIVE THERAPEUTIC SERVICES, LLC
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Dates
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Enumeration Date | 10/09/2020
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Last Update Date | 01/31/2021
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Provider Practice Location Address
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Address Line | 32910 W 13 MILE RD STE D-402
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City | FARMINGTON HILLS
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State | MI
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Zip | 48334-1980
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Country | US
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Telephone | 313-530-7916
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Fax |
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Provider Business Mailing Address
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Address Line | 26350 KILTARTAN ST
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City | FARMINGTON HILLS
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State | MI
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Zip | 48334-4834
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | KEVIN SPIZARNY
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Credential | LMSW
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Telephone | 248-983-3440
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0855X
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Taxonomy Name | Adolescent and Children Mental Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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