Provider Demographics
NPI:1578118980
Name:BRIGHT WHITE WAVE HEALING CENTER
Entity Type:Organization
Organization Name:BRIGHT WHITE WAVE HEALING CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GENEVIEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:248-766-2036
Mailing Address - Street 1:96 LYNDON CIR
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48363-1322
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:96 LYNDON CIR
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:MI
Practice Address - Zip Code:48363-1322
Practice Address - Country:US
Practice Address - Phone:248-766-2036
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-04
Last Update Date:2019-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1295079689Medicaid