Provider Demographics
NPI:1962842005
Name:MINDFUL MOMENTS LLC
Entity Type:Organization
Organization Name:MINDFUL MOMENTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LATISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRABOY
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD,LLPLMSW,ACSW
Authorized Official - Phone:888-508-0903
Mailing Address - Street 1:5737 HARVARD RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-2007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5737 HARVARD RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-2007
Practice Address - Country:US
Practice Address - Phone:888-508-0903
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-03
Last Update Date:2016-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health