Provider Demographics
NPI:1245014232
Name:SUPREME LIFE WELLNESS PLLC
Entity type:Organization
Organization Name:SUPREME LIFE WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAPP
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:313-522-4708
Mailing Address - Street 1:16970 NEW HAMPSHIRE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-2905
Mailing Address - Country:US
Mailing Address - Phone:313-522-4708
Mailing Address - Fax:
Practice Address - Street 1:16970 NEW HAMPSHIRE DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2905
Practice Address - Country:US
Practice Address - Phone:313-522-4708
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-22
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes104100000XBehavioral Health & Social Service ProvidersSocial WorkerGroup - Single Specialty