Provider Demographics
NPI:1376145557
Name:PROFOUND PSYCHOTHERAPY LLC
Entity Type:Organization
Organization Name:PROFOUND PSYCHOTHERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:THERAPIST
Authorized Official - Prefix:MS
Authorized Official - First Name:AZELDRI
Authorized Official - Middle Name:
Authorized Official - Last Name:VAN DER WATH
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:248-250-2530
Mailing Address - Street 1:41423 AMBERCREST DR
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-3719
Mailing Address - Country:US
Mailing Address - Phone:248-250-0253
Mailing Address - Fax:
Practice Address - Street 1:145 S LIVERNOIS RD # 113
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-1837
Practice Address - Country:US
Practice Address - Phone:248-250-0253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-11-12
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty
No104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Multi-Specialty