Provider Demographics
NPI:1649677527
Name:AGHATA CENTER FOR HEALING, LLC
Entity type:Organization
Organization Name:AGHATA CENTER FOR HEALING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:586-256-5820
Mailing Address - Street 1:39060 PINERIDGE ST
Mailing Address - Street 2:
Mailing Address - City:HARRISON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48045-2084
Mailing Address - Country:US
Mailing Address - Phone:586-256-5820
Mailing Address - Fax:
Practice Address - Street 1:44056 MOUND RD
Practice Address - Street 2:SUITE103
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1357
Practice Address - Country:US
Practice Address - Phone:586-256-5820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-20
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801083242251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
12210120OtherCAQH
MIP30210003Medicare PIN