=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801288931
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AUTHENTIC LIVING THERAPY CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2015
-----------------------------------------------------
Last Update Date | 02/26/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 254 FAIRGROVE
-----------------------------------------------------
City | ROMEO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-260-9014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 254 FAIRGROVE
-----------------------------------------------------
City | ROMEO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48065
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-260-9014
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. SARAH KAYE MURRAY
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 586-260-9014
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801088241
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------