Provider Demographics
NPI:1821360363
Name:MIND BODY AND SOUL PSYCHIATRIC SERVICES
Entity Type:Organization
Organization Name:MIND BODY AND SOUL PSYCHIATRIC SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAPMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:313-530-3452
Mailing Address - Street 1:23744 CORA AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48336-2620
Mailing Address - Country:US
Mailing Address - Phone:313-530-3452
Mailing Address - Fax:
Practice Address - Street 1:25882 ORCHARD LAKE RD
Practice Address - Street 2:SUITE L-5A
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48336-1292
Practice Address - Country:US
Practice Address - Phone:313-530-3452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076878261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center