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General NPI Number Information
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NPI Number | 1730683368
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Entity Type | Organization
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Legal Business Name | PEACE OF MIND THERAPY, PLLC
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Dates
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Enumeration Date | 03/20/2018
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Last Update Date | 05/05/2018
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Provider Practice Location Address
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Address Line | 2615 W 12 MILE RD STE 119
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City | BERKLEY
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State | MI
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Zip | 48072-1627
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Country | US
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Telephone | 248-397-4705
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Fax |
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Provider Business Mailing Address
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Address Line | 2615 W 12 MILE RD STE 119
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City | BERKLEY
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State | MI
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Zip | 48072-1627
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Country | US
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Telephone | 248-397-4705
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Fax |
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Authorized Official
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Title or Position | OWNER/CLINICAL THERAPIST
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Name | LAUREN LUCIELLE PROVENCHER
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Credential | LMSW
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Telephone | 248-397-4705
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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 | 6801093391
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License Number State | MI
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