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General NPI Number Information
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NPI Number | 1477805463
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Entity Type | Organization
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Legal Business Name | THE MINDFUL SELF, LLC
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Dates
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Enumeration Date | 10/15/2012
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Last Update Date | 12/12/2024
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Provider Practice Location Address
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Address Line | 31201 CHICAGO RD S STE A201
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City | WARREN
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State | MI
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Zip | 48093-5552
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Country | US
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Telephone | 248-543-0033
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Fax | 248-548-5309
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Provider Business Mailing Address
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Address Line | 31201 CHICAGO RD S STE A201
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City | WARREN
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State | MI
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Zip | 48093-5552
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Country | US
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Telephone | 248-543-0033
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Fax | 248-548-5309
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Authorized Official
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Title or Position | CLINICAL PSYCHOLOGIST
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Name | DR. ALISA M HILEWSKY
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Credential | PSYD, LLP, LPC
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Telephone | 248-543-0033
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 6301024395
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6401011013
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License Number State | MI
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