Provider Demographics
NPI:1033980461
Name:MICROCOSM, LLC
Entity Type:Organization
Organization Name:MICROCOSM, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/FOUNDER
Authorized Official - Prefix:
Authorized Official - First Name:AYYUR
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:231-912-1131
Mailing Address - Street 1:203 N WASHINGTON ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-2519
Mailing Address - Country:US
Mailing Address - Phone:231-912-1131
Mailing Address - Fax:
Practice Address - Street 1:203 N WASHINGTON ST UNIT 1
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2519
Practice Address - Country:US
Practice Address - Phone:231-912-1131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-01-15
Last Update Date:2024-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health