Provider Demographics
NPI:1982935029
Name:INTEGRATIVE HEALING ARTS CENTER
Entity Type:Organization
Organization Name:INTEGRATIVE HEALING ARTS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:LOVELL
Authorized Official - Last Name:MARBURY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-777-1053
Mailing Address - Street 1:23770 JOHNSTON AVE
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-3420
Mailing Address - Country:US
Mailing Address - Phone:586-777-1053
Mailing Address - Fax:
Practice Address - Street 1:23770 JOHNSTON AVE
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-3420
Practice Address - Country:US
Practice Address - Phone:586-777-1053
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTEGRATIVE COUNSELING SERVICES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-01-28
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI205435100Medicaid
MI205435100Medicaid