Provider Demographics
NPI:1790320091
Name:WINGS OF FREEDOM PSYCHOLOGICAL CARE PLLC
Entity Type:Organization
Organization Name:WINGS OF FREEDOM PSYCHOLOGICAL CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:AMELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:RIVAS
Authorized Official - Suffix:
Authorized Official - Credentials:MS, LLP, PLLC
Authorized Official - Phone:248-444-7378
Mailing Address - Street 1:3850 DEMEAN ST
Mailing Address - Street 2:
Mailing Address - City:MELVINDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48122-1623
Mailing Address - Country:US
Mailing Address - Phone:248-444-7378
Mailing Address - Fax:
Practice Address - Street 1:2514 BIDDLE AVE
Practice Address - Street 2:
Practice Address - City:WYANDOTTE
Practice Address - State:MI
Practice Address - Zip Code:48192-7891
Practice Address - Country:US
Practice Address - Phone:248-444-7891
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-10
Last Update Date:2019-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty