MEDICARE: AGHATA CENTER FOR HEALING, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251S00000X	Community/Behavioral Health Agency	6801083242	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	12210120	OTHER		CAQH

General Provider Information

NPI Number	:	1649677527
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AGHATA CENTER FOR HEALING, LLC

Provider Business Mailing Address
First Line	:	39060 PINERIDGE ST
Second Line	:
City	:	HARRISON TOWNSHIP
State	:	MI
Zip	:	48045-2084
Country	:	US
Telephone Number	:	586-256-5820
Fax Number	:

Provider Business Practice Location Address
First Line	:	44056 MOUND RD
Second Line	:	SUITE103
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48314-1357
Country	:	US
Telephone Number	:	586-256-5820
Fax Number	:

Authorized Official
Title or Position	:	CLINICAL DIRECTOR
Name	:	JULIE ANN PHILLIPS
Credential	:	LMSW
Telephone Number	:	586-256-5820

Provider Enumeration Date	:	11/20/2014
Last Update Date	:	12/22/2014

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