Provider Demographics
NPI:1730683368
Name:PEACE OF MIND THERAPY, PLLC
Entity type:Organization
Organization Name:PEACE OF MIND THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:LAUREN
Authorized Official - Middle Name:LUCIELLE
Authorized Official - Last Name:PROVENCHER
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-397-4705
Mailing Address - Street 1:2615 W 12 MILE RD STE 119
Mailing Address - Street 2:
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-1627
Mailing Address - Country:US
Mailing Address - Phone:248-397-4705
Mailing Address - Fax:
Practice Address - Street 1:2615 W 12 MILE RD STE 119
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-1627
Practice Address - Country:US
Practice Address - Phone:248-397-4705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-20
Last Update Date:2018-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010933911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1285918631OtherBCBS/BCN