Provider Demographics
NPI:1407020993
Name:THE HEALING PALACE INC
Entity Type:Organization
Organization Name:THE HEALING PALACE INC
Other - Org Name:DIVINE INTERVENTIONS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:FOUNDER AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHONTAY
Authorized Official - Middle Name:DETRIA
Authorized Official - Last Name:TAYLOR GLENN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, RN, PMHNP-BC
Authorized Official - Phone:313-459-6707
Mailing Address - Street 1:2089 ANITA AVE
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48236-1427
Mailing Address - Country:US
Mailing Address - Phone:313-459-6707
Mailing Address - Fax:313-731-0360
Practice Address - Street 1:2089 ANITA AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1427
Practice Address - Country:US
Practice Address - Phone:313-459-6707
Practice Address - Fax:313-731-0360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI470408682251S00000X
261QM0801X
MI4704208682322D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No251S00000XAgenciesCommunity/Behavioral Health
No322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P48690Medicare UPIN