Provider Demographics
NPI:1568964872
Name:BEAUTIFUL MIND FAMILY COUNSELING SERVICES, LLC
Entity Type:Organization
Organization Name:BEAUTIFUL MIND FAMILY COUNSELING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LACARA
Authorized Official - Middle Name:S
Authorized Official - Last Name:GILMORE
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:734-404-8729
Mailing Address - Street 1:15056 COLBERT ST.
Mailing Address - Street 2:03
Mailing Address - City:ROMULUS
Mailing Address - State:MI
Mailing Address - Zip Code:48174-4817
Mailing Address - Country:US
Mailing Address - Phone:313-401-2655
Mailing Address - Fax:
Practice Address - Street 1:15056 COLBERT ST.
Practice Address - Street 2:03
Practice Address - City:ROMULUS
Practice Address - State:MI
Practice Address - Zip Code:48174-4817
Practice Address - Country:US
Practice Address - Phone:313-401-2655
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-02
Last Update Date:2018-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106H00000X
MI4101006791106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI00069Medicaid