Provider Demographics
NPI:1467021741
Name:MOSTYN, OMEGA C (LPC)
Entity Type:Individual
Prefix:MS
First Name:OMEGA
Middle Name:C
Last Name:MOSTYN
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15001 KERCHEVAL AVE STE 384
Mailing Address - Street 2:
Mailing Address - City:GROSSE POINTE PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48230-1361
Mailing Address - Country:US
Mailing Address - Phone:313-408-9179
Mailing Address - Fax:
Practice Address - Street 1:26522 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:CENTER LINE
Practice Address - State:MI
Practice Address - Zip Code:48015-1221
Practice Address - Country:US
Practice Address - Phone:586-759-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401019468101YP2500X
MI6401223696101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional