Provider Demographics
NPI:1205441722
Name:FAITH AND RADICAL SELF-LOVE, LLC
Entity type:Organization
Organization Name:FAITH AND RADICAL SELF-LOVE, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:THERAPIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ZENOBIA
Authorized Official - Middle Name:
Authorized Official - Last Name:KINDLE-DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-854-5102
Mailing Address - Street 1:22804 SHARROW AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-2882
Mailing Address - Country:US
Mailing Address - Phone:313-854-5102
Mailing Address - Fax:313-251-7344
Practice Address - Street 1:22804 SHARROW AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-2882
Practice Address - Country:US
Practice Address - Phone:313-854-5102
Practice Address - Fax:313-251-7344
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-11
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)