Provider Demographics
NPI:1144050329
Name:BRAIN SPACE WELLNESS PLLC
Entity type:Organization
Organization Name:BRAIN SPACE WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MEAGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-215-5586
Mailing Address - Street 1:1700 W STADIUM BLVD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-5225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:116 E WASHINGTON ST STE 209
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-1938
Practice Address - Country:US
Practice Address - Phone:734-215-5586
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-03
Last Update Date:2024-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health