=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932843984
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHY MIND HEALTHY LIFE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2022
-----------------------------------------------------
Last Update Date | 11/08/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17515 W 9 MILE RD STE 650
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-963-8189
-----------------------------------------------------
Fax | 763-402-7611
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17515 W 9 MILE RD STE 650
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-4403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-633-8385
-----------------------------------------------------
Fax | 763-402-7611
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LARISSA BARCLAY
-----------------------------------------------------
Credential | DNP, NP-C, PMHNP-BC
-----------------------------------------------------
Telephone | 248-963-8189
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------