Provider Demographics
NPI:1003376112
Name:STATE OF MIND COUNSELING CENTERS LLC
Entity Type:Organization
Organization Name:STATE OF MIND COUNSELING CENTERS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:CARRISSA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MICHAEL
Authorized Official - Suffix:
Authorized Official - Credentials:MA, LPC, NCC, LLMFT
Authorized Official - Phone:248-521-8237
Mailing Address - Street 1:140 FONTAINBLEAU CT E
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-2421
Mailing Address - Country:US
Mailing Address - Phone:248-521-8237
Mailing Address - Fax:
Practice Address - Street 1:52188 VAN DYKE AVE STE 319
Practice Address - Street 2:
Practice Address - City:SHELBY TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48316-3571
Practice Address - Country:US
Practice Address - Phone:248-690-6851
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-24
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1770927147OtherNPI