=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780450031
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CONSCIOUS GARDEN COUNSELING LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/28/2023
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1149 HILTON RD # 200
-----------------------------------------------------
City | FERNDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48220-2838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-228-6404
-----------------------------------------------------
Fax | 313-331-6824
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1149 HILTON RD # 200
-----------------------------------------------------
City | FERNDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48220-2838
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-228-6404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOCIAL WORKER-THERAPIST
-----------------------------------------------------
Name | JESICA A BASSETT
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 517-231-7183
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------