Provider Demographics
NPI:1083990485
Name:MIND AND BODY HOLISTIC THERAPY
Entity Type:Organization
Organization Name:MIND AND BODY HOLISTIC THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARIFA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARVEY
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW-SSW
Authorized Official - Phone:313-422-3109
Mailing Address - Street 1:29 MASSACHUSETTS ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203
Mailing Address - Country:US
Mailing Address - Phone:313-422-3109
Mailing Address - Fax:
Practice Address - Street 1:440 BURROUGHS ST.
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-422-3109
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-30
Last Update Date:2011-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010855601041C0700X, 1041S0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchoolGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty