Provider Demographics
NPI:1063076008
Name:IMAGINE COUNSELING
Entity type:Organization
Organization Name:IMAGINE COUNSELING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:GRACIE
Authorized Official - Last Name:BROCKERT
Authorized Official - Suffix:
Authorized Official - Credentials:LLMSW
Authorized Official - Phone:586-460-8830
Mailing Address - Street 1:20601 YALE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48081-1779
Mailing Address - Country:US
Mailing Address - Phone:586-460-8830
Mailing Address - Fax:
Practice Address - Street 1:20601 YALE ST
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48081-1779
Practice Address - Country:US
Practice Address - Phone:586-460-8830
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-25
Last Update Date:2019-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health