Provider Demographics
NPI:1013145879
Name:MINDFUL LIVING PLLC
Entity type:Organization
Organization Name:MINDFUL LIVING PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBBIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOELTZOW
Authorized Official - Suffix:
Authorized Official - Credentials:EDD, LP
Authorized Official - Phone:734-657-8059
Mailing Address - Street 1:2460 CARRIAGE WAY
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-7423
Mailing Address - Country:US
Mailing Address - Phone:734-657-8059
Mailing Address - Fax:810-588-4247
Practice Address - Street 1:810 E GRAND RIVER AVE STE 101
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1878
Practice Address - Country:US
Practice Address - Phone:810-588-4236
Practice Address - Fax:810-588-4247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301011430103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty