=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609394139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WISE OLD OWL THERAPY, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/05/2017
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11135 DAWN DR
-----------------------------------------------------
City | FOWLERVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48836-9296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-360-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11135 DAWN DR
-----------------------------------------------------
City | FOWLERVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48836-9296
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 810-360-7000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/THERAPIST
-----------------------------------------------------
Name | MISS ELIZABETH VIOLA CURD
-----------------------------------------------------
Credential | MAT/MAC/NCC
-----------------------------------------------------
Telephone | 810-360-7000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 6401016102
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------