Basic Information
| Provider Information | |||||||||
| NPI: | 1063901833 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INNERESSENCE COUNSELING AND CLINICAL HYPNOTHERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18465 SOUTH DR APT 173 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480761133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2484709959 | ||||||||
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| Practice Location | |||||||||
| Address1: | 380 N OLD WOODWARD AVE STE 156 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480095307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488275583 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2018 | ||||||||
| LastUpdateDate: | 05/07/2018 | ||||||||
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| AuthorizedOfficialLastName: | SIMON | ||||||||
| AuthorizedOfficialFirstName: | CAROLYN | ||||||||
| AuthorizedOfficialMiddleName: | JEAN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER/PROFESSIONAL COUNSELOR | ||||||||
| AuthorizedOfficialTelephone: | 2488275583 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | LPC, C.HT | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 101YP1600X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Pastoral | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.