Healthcare Provider Details

I. General information

NPI: 1760105035
Provider Name (Legal Business Name): KIMBERLY FORBES-DYCZKOWSKI TLLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2022
Last Update Date: 09/25/2026
Certification Date: 09/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 WASHTENAW AVE STE 282
ANN ARBOR MI
48104-5184
US

IV. Provider business mailing address

3062 BERKSHIRE CT
MILFORD MI
48380-3238
US

V. Phone/Fax

Practice location:
  • Phone: 248-764-8787
  • Fax:
Mailing address:
  • Phone: 248-764-8787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6351004995
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: