=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851099949
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RARE MIND AND BODY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2023
-----------------------------------------------------
Last Update Date | 05/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 36661 MAIN ST
-----------------------------------------------------
City | NEW BALTIMORE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48047-2552
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-675-8424
-----------------------------------------------------
Fax | 586-500-5660
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28111 JEFFERSON AVE APT E6
-----------------------------------------------------
City | SAINT CLAIR SHORES
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48081-2523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-675-8424
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHOTHERAPIST
-----------------------------------------------------
Name | IMAGINE MUSARAJ
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 586-943-9306
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------