Provider Demographics
NPI:1063093292
Name:I'M YOUR THERAPIST, LLC
Entity type:Organization
Organization Name:I'M YOUR THERAPIST, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:
Authorized Official - Last Name:ORNS-GRANT
Authorized Official - Suffix:
Authorized Official - Credentials:LISW
Authorized Official - Phone:269-339-8531
Mailing Address - Street 1:1715 INDIAN WOOD CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-4055
Mailing Address - Country:US
Mailing Address - Phone:269-339-8531
Mailing Address - Fax:
Practice Address - Street 1:1715 INDIAN WOOD CIRCLE
Practice Address - Street 2:STE 200
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537
Practice Address - Country:US
Practice Address - Phone:269-339-8531
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-19
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)