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General NPI Number Information
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NPI Number | 1639600687
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Entity Type | Organization
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Legal Business Name | DEEPWATER COUNSELING, PLLC
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Dates
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Enumeration Date | 03/22/2017
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Last Update Date | 01/14/2021
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Provider Practice Location Address
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Address Line | 3150 PACKARD RD
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City | YPSILANTI
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State | MI
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Zip | 48197-1994
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Country | US
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Telephone | 734-203-0183
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Fax |
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Provider Business Mailing Address
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Address Line | 10672 NORTHWOOD HWY
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City | ONEKAMA
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State | MI
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Zip | 49675-9612
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Country | US
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Telephone | 734-776-8251
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MRS. JENNIFER BLOUGH
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Credential | LPC
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Telephone | 734-776-8251
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 6401014637
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License Number State | MI
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