Provider Demographics
NPI:1083346225
Name:THE NELSON CENTER FOR MINDFUL SYNERGY
Entity type:Organization
Organization Name:THE NELSON CENTER FOR MINDFUL SYNERGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:ROSE
Authorized Official - Last Name:HUMPHREYS
Authorized Official - Suffix:
Authorized Official - Credentials:LLMSW
Authorized Official - Phone:313-903-3955
Mailing Address - Street 1:517 ARDMORE DR
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-3321
Mailing Address - Country:US
Mailing Address - Phone:313-903-3955
Mailing Address - Fax:
Practice Address - Street 1:517 ARDMORE DR
Practice Address - Street 2:
Practice Address - City:FERNDALE
Practice Address - State:MI
Practice Address - Zip Code:48220-3321
Practice Address - Country:US
Practice Address - Phone:313-903-3955
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-27
Last Update Date:2022-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1861680456Medicaid