Provider Demographics
NPI:1740750736
Name:MITTEN CENTER FOR PSYCHOLOGICAL TRAUMA, LLC
Entity Type:Organization
Organization Name:MITTEN CENTER FOR PSYCHOLOGICAL TRAUMA, LLC
Other - Org Name:MITTEN CENTER FOR PSYCHOLOGICAL TRAUMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:TERRA
Authorized Official - Middle Name:LAQUAY
Authorized Official - Last Name:GINTHER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-720-9833
Mailing Address - Street 1:28800 HARPER AVE STE A
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1249
Mailing Address - Country:US
Mailing Address - Phone:586-350-0013
Mailing Address - Fax:586-350-0013
Practice Address - Street 1:28800 HARPER AVE STE A
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081
Practice Address - Country:US
Practice Address - Phone:586-350-0013
Practice Address - Fax:586-350-0042
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-03
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty