Basic Information
| Provider Information | |||||||||
| NPI: | 1750735197 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MI HEALING SPACE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 ABBOT RD | ||||||||
| Address2: | STE 103 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488233366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175744197 | ||||||||
| FaxNumber: | 5175744201 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 ABBOT RD | ||||||||
| Address2: | STE 103 | ||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488233366 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5175744197 | ||||||||
| FaxNumber: | 5175744201 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2016 | ||||||||
| LastUpdateDate: | 05/03/2016 | ||||||||
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| AuthorizedOfficialLastName: | WOOD | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | LMSW | ||||||||
| AuthorizedOfficialTelephone: | 5178622197 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801095863 | MI | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.