1457890014 NPI number — HEALING WATERS COUNSELING SERVICES,PLLC

Table of content: (NPI 1457890014)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457890014 NPI number — HEALING WATERS COUNSELING SERVICES,PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALING WATERS COUNSELING SERVICES,PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457890014
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/15/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11291 MCKINNEY ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48224-1114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-480-1826
Provider Business Mailing Address Fax Number:
313-521-1902

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
29556 SOUTHFIELD RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHFIELD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48076-2021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-480-1826
Provider Business Practice Location Address Fax Number:
313-521-1902
Provider Enumeration Date:
02/15/2017

Additional Information

Authorized Official

Authorized Official Last Name:
MCGHEE
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
ANGEL
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
248-480-1246

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  6401009379 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1386025948 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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