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General NPI Number Information
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NPI Number | 1831943026
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Entity Type | Organization
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Legal Business Name | PROVISIONAL THERAPY ASSOCIATES
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Dates
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Enumeration Date | 04/15/2024
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Last Update Date | 04/15/2024
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Provider Practice Location Address
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Address Line | 4241 BRECKENRIDGE DR
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City | WEST BLOOMFIELD
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State | MI
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Zip | 48322-4430
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Country | US
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Telephone | 248-240-2963
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Fax |
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Provider Business Mailing Address
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Address Line | 4241 BRECKENRIDGE DR
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City | WEST BLOOMFIELD
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State | MI
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Zip | 48322-4430
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Country | US
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Telephone | 248-240-2963
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Fax |
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Authorized Official
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Title or Position | GROUP REPRESENTATIVE
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Name | LINA MARI ESCAMILLA
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Credential | LMSW
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Telephone | 248-240-2963
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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 |
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License Number State |
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