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General NPI Number Information
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NPI Number | 1699170266
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Entity Type | Organization
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Legal Business Name | AGEWELL FAMILY COUNSELING, LLC
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Dates
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Enumeration Date | 10/24/2014
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Last Update Date | 12/26/2014
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Provider Practice Location Address
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Address Line | 167 OLD PERCH RD
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City | ROCHESTER HILLS
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State | MI
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Zip | 48309-2135
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Country | US
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Telephone | 810-874-0857
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Fax |
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Provider Business Mailing Address
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Address Line | 167 OLD PERCH RD
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City | ROCHESTER HILLS
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State | MI
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Zip | 48309-2135
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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 | FOUNDING MEMBER
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Name | YULIYA GAYDAYENKO
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Credential | LMSW
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Telephone | 810-874-0857
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | 6801089424
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License Number State | MI
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