MEDICARE: MRS. LA-TOYA SHANNELLE GAINES PSY.D. L.P.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	6301015276	MI
2	103TC2200X	Clinical Child & Adolescent Psychologist	6301015276	MI

General Provider Information

NPI Number	:	1356678320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LA-TOYA SHANNELLE GAINES PSY.D. L.P.

Provider Business Mailing Address
First Line	:	29532 SOUTHFIELD RD
Second Line	:	SUITE #101
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-2023
Country	:	US
Telephone Number	:	313-449-3913
Fax Number	:

Provider Business Practice Location Address
First Line	:	29532 SOUTHFIELD RD
Second Line	:	SUITE #101
City	:	SOUTHFIELD
State	:	MI
Zip	:	48076-2023
Country	:	US
Telephone Number	:	313-449-3913
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/11/2009
Last Update Date	:	04/20/2016

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